· 2020. 7. 31. · the hillingdon hospitals nhs foundation trust meeting of the council of...

The Hillingdon Hospitals NHS Foundation Trust

Meeting of the Council of Governors

Tuesday 04 Aug 2020 at 6.00 – 8.00pm

Via MS Teams

It is currently intended the meeting will be a live TEAMs event open to the public. It will also be recorded and made available after the event

AGENDA

Item Lead Enc PRIVATE MEETING

1. To discuss Annual Report and Accounts with the Trust Auditors Deloitte To note – The Annual Report will be shared with the public at the Annual Members Meeting

Chair of Audit and Risk Committee

Deloitte

Reports AB

PUBLIC MEETING

2. Welcome and Apologies for Absence

Chair Verbal

3. Declarations of Interest Chair Verbal

4. Minutes of the meeting held on 05 May 2020

Chair Minutes C

5. Action log Chair Action Log - 6. Matters Arising

7. Chair’s Report Chair Verbal

8. Chief Executive’s Update CEO Report D

9. Presentation on current developments including modular wards

CEO Presentation E

10. Presentation on engagement planning for the New Hospital Development following approval of the Strategic Outline Case at the July Trust Board meeting

Head of Communications

Presentation F

11. Update on election planning arrangements

Trust Secretary Civica

Report G

THHFT Council of Governors' Meeting: 04/08/2020 of 87

12. Update on plans for the Annual Members Meeting/AGM

Trust Secretary Verbal

13. Governance Update Trust Secretary Report for noting

H

14. Any Other Business Chair Verbal

15. Questions from Governors Chair Verbal 16. Date of Next Meeting:

o 22 September 2020 –Annual MembersMeeting 5 – 6 pmvirtual

o 03 November 2020 6 –8 pm

At the November meeting and post elections the following will take place: • Induction for new Governors• Training session around:

o Role and Responsibilities of Governorso Engaging with our communities which will include feedback from

Governors on how they currently do so to share learning


Present:

Sir Amyas Morse, Chair Tony Ellis, Lead Governor (Public) Graham Bartram, Public Governor Ian Bendall, Public Governor Des Brown, Public Governor Rosemary Jenkins, Public Governor Robin Launder, Public Governor Ahmet Moustafa, Public Governor Kamran Qureshi, Public Governor Mohan Sharma, Public Governor Rekha Wadhwani, Public Governor Jack Creagh, Staff Governor Gillian Pearce, Staff Governor Angela Joseph, Appointed Governor Natasha Wills, Appointed Governor Amanda O’Brien, Public Governor Lynn Hill, Appointed Governor

In Attendance:

Sarah Tedford, Chief Executive Professor Lis Paice, NED and Deputy Chair Jason Seez, Deputy CEO & Director of Strategy Janet Campbell, NED Catherine Jervis, NED Dr Linda Burke, NED Richard Whittington, NED/SID Justine McGuinness, Director Communications and Engagement Simon Morris, NED Deborah Lawrenson, Trust Secretary Michael Wood, GGI Consultant Pooja Sharma, Assistant Trust Secretary (taking minutes)

Members of the Public: There were no members of the public present in this meeting as the meeting was held via MS Teams.

1. Welcome and Apologies for Absence

The Chair welcomed all to the meeting. Apologies for absence were received from Dr. Arindam Basu (Staff Governor), Marian Thompson

THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST

MINUTES OF THE COUNCIL OF GOVERNORS

Tuesday 05th May 2020 at 6:30 pm

Virtual meeting via MS Teams


(Public Governor) and Lubna Hussain (Staff Governor). The Chair commended Michael Wood (Interim Trust Secretary) for his support to the Council and the Board over the past year and introduced the new Trust Secretary, Director of Communications, and Assistant Trust Secretary to the Council.

2. Declarations of Interest

There were no Declarations of Interest.

3. The Minutes of the meeting held on 11 February 2020 were approved and accepted as accurate record.

4. Matters Arising and Action Log

There were no matters arising or actions to follow up, with the exception of the need to upload the updated Constitution on the Trust website, which it was confirmed was in hand.

5. Chair’s Introduction

The Chair presented his report to Council, referring, in particular, to seeking detailed assurance from CEO on the conduct of some of the consultants in the crisis, on the supply chain of PPE as experienced by HHT, and on the enduring problem of timely issuing of patient discharge summaries.

The Chair emphasised that ad hoc Board Seminar meetings were put into place to discuss issues of significant concern with the executives.

The Chair wished to record his sincere thanks to the CEO and her team for their leadership and to all staff in the Trust for how they had worked together and with colleagues in the wider health economy and the community in meeting the challenges of Covid-19.

6. Chief Executive’s update

The Deputy Chief Executive and Chief Executive advised the council and provided assurance on the extensive level of preparation that was taking place in respect of PPE supplies and emergency & urgent care. The key areas which of focus being safety and capacity of the hospital to deal with the COVID patients. The critical care departments and medical assessment unit have shown significant progress and responded well.

Specifically with regard to Coronavirus (Covid-19), the Council noted that a large number of actions had been taken to ensure the Trust is in compliance with the national and regional guidelines. It was reported that the Trust had ensured that the Governance systems for Quality, safety, had been maintained.

With regard to statistics, Governors noted the current COVID position as at 30 April 2020. The data had been provided to Council members prior to the meeting, as part of the Chief Executive’s Report.


The Deputy CEO and CEO talked through various aspects and steps taken around staff welfare, communication and engagement, and work being taken forward in respect of the wider health and care system. They stated that lot of work has been done and was continuing with regard to Out-patient transformation and the management was considering changes which had taken place as an opportunity to continue to evolve the Trust’s services post COVID.

7. Report from Governors’ Nomination & Remuneration Committee

The lead Governor presented his report and Council noted the committee had approved proposals to defer NED appraisals and given the delay to Council elections, continuing with the current composition of the Committee until the November 2020 Council of Governors’ Meeting.

The lead Governor further proposed in his report that recognising the extra work load of the Deputy Chair, and following a bench-marking exercise carried out by the Director of People, the remuneration of the Deputy Chair should be increased to the amount recommended by the Committee, back dated to 1 October 2019.

The Council approved the proposal of the Governors’ Nomination & Remuneration Committee as outlined above.

8. Any Other Business

In response to a question relating to improvements to the communication of Trust with the Council and members, the Trust Secretary confirmed she would be arranging 1:1 meetings with the Governors to gather feedback to support future planning.

Council members noted their appreciation of the daily Covid-19 bulletin being provided which some members confirmed they were also sharing through their own social media sites. The Council noted it would be helpful to build on approach to communications in the future by continuing to share similar regular bulletins,

Responding to a question in respect of complaints and response times, the Deputy Chair advised that the Governors that the Quality & Safety Committee was keeping this matter (and also the historic discharge summary backlog) under close review.

The Council agreed that it was important to communicate as effectively as possible with all Governors and staff and that this was being taken forward by the Trust Secretary and the Director of Communications and Engagement.

9. Questions from the Governors

Arising out of discussion and following receipt of questions from members in advance of the meeting, the Deputy Chair summarised the questions from the Governors as follows:


• How the Chair’s association with London North WestHealthcare NHS Trust has benefitted Hillingdon hospitals?

• Who is the appropriate point of contact, as in CoGs/NEDs/EDsto pose questions and send replies? Can Governors havemore details in the minutes of the content of the NED report?

• How to ensure the circulation of meeting papers in time? Whatwork has been done so far to improve the timeliness ofdischarge summaries, with regards to timely discharge,language, etc.?

• When can patients expect to get letters from consultantsaddressed to them, in language they can understand?

• What is the status of PPE supplies?• When is our staff getting tested for COVID?• When are emergency services, elective work and surgeries

expected to start again? How is the Trust managing thosepatients whose pathways were disrupted by the need to createcapacity to deal with the pandemic?

• How the suspension of services for non-COVID patients isgoing to effect the patient pathway in the short and long runand what measures are planned by the hospital to bring thesystem in line, post COVID or when the services areresumed?

• How many staff members are infected and how severely?• What is the status of the supply of oxygen facilities?• Are the NEDs satisfied by the responses and how do they

assure themselves that quality of care is being maintained?• What assurance can NEDs provide to the members on the

prevailing situation?• Is monitoring of the asbestos carried out in the old wartime

huts and what types of asbestos are we aware of at thehospital?

• At the last fire exercise there were several weak areas, havethese been sorted?

• How to expand the roles of volunteers?• When can we expect Good or Outstanding CQC rating for the

Hillingdon Hospitals?

The Trust had self-assessed at Requires Improvement overall, though the COVID-19 efforts by staff have been outstanding. The CEO reiterated that monitoring and evaluation of performance was continuous, and a number of good things have been embedded in the process. Once things settle down we will reassess our position with regard to progress made, areas where further effort is needed and the realignments & reorientations demanded by CQC.

In response to other questions on Coronavirus, the following feedback was provided:

• The Trust had very clear policies and protocols for dealing withCOVID which had been effectively put into operation.

• The procurement team has ensured sufficient PPE suppliesfor the staff and the issues have been addressed. Supplies arebeing coordinated at NWL level so as to make sure they are


fairly distributed. • The senior and junior staff had been going through rigorous

training them to cope up with the difficult shifts and demandingtimes, ensuring continuing high quality care.

• Testing of staff is already underway. Onsite testing of the staffis going to start soon and the Trust is well prepared to do so.

• Elective services are expected to resume as per the Nationalguidelines. Interrupted Patient pathways are being reset byclinicians and GPs as a priority.

• Staff sickness is continuously monitored to keep track of thenumber of staff infected and who are COVID positive, andrecovered. One member of staff had sadly died.

• Oxygen facilities are tested ahead of requirement by theEstates and Facility Department. Supplies are adequate.

Responding to a question in respect of assurances received by the NEDs, the Chair, Deputy Chair and NEDs confirmed the following:

• Standard Quality Indicators are shared with the NEDs in theBoard Meetings.

• Sub-committee meetings, phone calls with colleagues, etc. arearranged to get a true picture.

• NEDs have weekly group and individual meetings to discussvarious issues and concerns.

• The Chair asks for written reports from the CEO on specificissues the NEDs require assurance on.

• The Q&A sessions by the CEO are a good practice example insupporting understanding what is going on across the Trust.

• GGI weekly seminars aimed at NEDs support benchmarkingof the approach at Hillingdon with other Trusts.

• Family members of the patients who are receiving treatmentfor COVID are provided appropriate support.

Governors expressed their thanks for the outstanding efforts made by the staff during the COVID-19 crisis.

There being no other business to discuss, the Chair thanked everyone for their contribution to the meeting.

(Note: There were no members of the public in attendance)

Date of next meeting:

The date of the next meeting was provisionally confirmed as 3 September 2020 (Governors’ Briefing on 4 August 2020).

Post meeting note - The dates of the next two CoGs meetings are 4th August and 3rd November 2020. If there is an urgent need, an Extraordinary Meeting of the CoGs will be called.

Certified as a true record of the meeting


………………………………………….. The Chair- Sir Amyas Morse

………………………………………….. Date


ACTION LOG – Council of Governors Meeting to be received on 04 Aug 2020

Minute Ref

Paper/Agenda item Ref

CoGs meeting date where the action arose

ACTIONS Owner Due Date Progress update RAG

No actions were pending from the previous CoGs meeting. RAG RATING OWNERS

Key Completed On Track Some slippage Serious Issues

Name initials Sarah Tedford CEO Jason Seez Deputy CEO Tina Benson COO Dr Cathy Cale MD Camilla Wiley CN Deborah Lawrenson TS Tahir Ahmed DoE Belinda Norris CTO Sue Smith CPO Justine McGuinness DoComms


Chief Executive’s Report Council of Governors Meeting ITEM: 8

Date of the meeting: 04 Aug 2020 ENCLOSURE: D

Purpose of the Report/Paper:

To provide an update from the Chief Executive on the key issues.

For:

Information Assurance Discussion and input Decision/approval

Executive summary:

This report provides an update on:

• COVID-19• New Hospital Development• Quality & Safety• People• Performance• Finances

Sponsor (Executive Lead): Sarah Tedford, Chief Executive

Author: The Executive Team

Author contact details: [email protected]

Risk implications – Link to Board Assurance Framework or Corporate Risk Register:

All relevant Covid Risk Register

Legal/Regulatory/Finance/Quality & Safety/ HR/E&D/Engagement/Communications/Reputation or Sustainability implications:

All

Link to Relevant CQC Domain:

Safe Effective Caring Responsive Well Led

Link to relevant Corporate Objectives/strategic aims:

All

Document previously considered by: NA Recommendations: The Council of Governors is asked to note the information provided in the report.


ENCLOSURE

The Hillingdon Hospitals NHS Foundation Trust – Council of Governor Elections 2020

Council of Governors Meeting

ITEM: 11

Date of the meeting: 04 Aug 2020 ENCLOSURE: G

Purpose of the Report/Paper: To provide the Council of Governors with an updated on the Election process. For: fill the box that is relevant Information Assurance Discussion and input Decision/approval Executive summary: NA Sponsor (Executive Lead):

Deborah Lawrenson, Trust Secretary

Author:

Richard Jones, Consultant and Simon Clarke, Commercial and Relationship Manager- CIVICA

Author contact details:

[email protected]; [email protected]


Not specifically applicable


Compliance

Link to Relevant CQC Domain: Safe Effective Caring Responsive Well Led Link to relevant Corporate Objectives/strategic aims:

Not specifically applicable

Document previously considered by: NA Recommendations: The Council is asked to note the progress from CIVICA on the Election of Governors 2020.


mailto:[email protected]

mailto:[email protected]

Civica Election Services Limited The Election Centre 33 Clarendon Road London N8 0NW T: +44 (0) 20 8365 8909 E: [email protected] W: civica.com/electionservices

Registered in England, number: 02263092 Registered Address: Southbank Central, 30 Stamford Street London, SE1 9LQ

The Hillingdon Hospitals NHS Foundation Trust – Council of Governor Elections 2020

Background

On 2 March 2020 the Trust published the Notice of Election for 13 Public and 7 Staff Governor vacancies as follows:

13 PUBLIC GOVERNORS IN THE FOLLOWING CONSTITUENCIES

Constituency Vacancies Term Length Hillingdon Central 4 3 Years Hillingdon North 4 3 Years Hillingdon South 4 3 Years Rest of England 1 3 Years

7 STAFF GOVERNORS IN THE FOLLOWING CONSTITUENCIES

Constituency Vacancies Term Length Allied Health Professional, Scientific and Technical 1 3 Years

Doctor and Dentist 1 3 Years Nurses, Midwives & HCAs 3 3 Years

Support Staff 2 3 Years

Nominations closed at 5pm on Friday 20 March 2020. The Statement of Nominated Candidates was published on Tuesday 24 March 2020 with a candidate withdrawal period concluding 5pm on Thursday 26 March.

On Friday 27 March CES, as Returning Officers provided an Uncontested Report to the Trust (for Constituencies where the number of valid nominations received was equal to, or less that the number of vacancies published) and in consultation with the Trust and in line with the NHS England COVID-19 guidance “paused” the election process prior to publishing a Notice of Poll and the distribution of voting material to eligible electors.

All nominees that would have contested the election were informed that this had now been delayed. One candidate who was due to contest the Support Staff Constituency election informed us that they were no longer employed by the Trust (and thus we note that they become ineligible to contest this election).


Next Steps:

1. As a result of the ineligibility of one of the three Support Staff nominees, only two valid candidates remain for the two vacancies. The Returning Officer will provide an Uncontested Report of Voting covering this Constituency.

2. A ballot is therefore required in the following Constituencies:

Constituency Vacancies Potential Nominees Notes

Hillingdon Central 4 6 Subject to Candidate Confirmation

Hillingdon North 4 6

Hillingdon South 4 8

1. We suggest that all nominees are asked to confirm their willingness to stand and that their electoral circumstances have not altered – i.e. they have not moved for example.

2. The Trust currently has a number of vacancies:

Constituency Vacancies

Rest of England 1

Staff: Doctor and Dentist 1

Staff: Nurses, Midwives & HCAs 2

3. In light of both the recently announced major hospital development and the pending review of the membership strategy the Trust Secretary and Lead Governor recommend that the Rest of England vacancy remain unfilled at present. This in our view will present no obvious issues as at the conclusion of this year’s elections and in accordance with the Constitution the number of Public Governors will exceed the sum of the Staff plus Appointed Governors.

4. In order to minimize any potential voter confusion, maximize cost efficiency and most importantly ensure that the election is concluded as soon as practical we suggest that the following timetable be considered:

ELECTION STAGE Timetable Trust to send nomination material and data to CES Tuesday, 4 Aug 2020 Notice of Election / nomination open Tuesday, 18 Aug 2020 Nominations deadline Thursday, 3 Sep 2020 Summary of valid nominated candidates published Friday, 4 Sep 2020 Final date for candidate withdrawal Tuesday, 8 Sep 2020 Electoral data to be provided by Trust Thursday, 10 Sep 2020 Notice of Poll published Tuesday, 22 Sep 2020 Voting packs despatched Wednesday, 23 Sep 2020 Close of election Tuesday, 13 Oct 2020 Declaration of results Wednesday, 14 Oct 2020

SC 29072020


of 13

GOVERNANCE UPDATE

Council of Governors meeting

ITEM: 13

Date of the meeting: 4 August 2020 ENCLOSURE: H

Purpose of the Report/Paper: To provide the Council of Governors with an updated protocol in respect of the requirements of the Fit and Proper Persons Test for Governors and for declaring interests. For: Information Assurance Discussion and input Decision/approval Executive summary: Fit and Proper Persons Test

• In line with our Constitution we are required to confirm compliance for Governors with The Fit and Proper Persons test for the current financial year. This process has been conducted for Board members and members of the Executive Team. As we will be shortly continuing with our election process we will also be conducting this with any new members of the Council however until such time as those individuals are in place we are required to confirm continued compliance for our existing Governors. Further detail is provided in the attached paper. Attached at Appendix A is the Fit and Proper Persons check list followed by the Fit and Proper Test declaration Form at Appendix B. Governors are asked to contact the Trust Secretary directly with any points for clarification and to submit completed forms by 31 August 2020.

Declarations of Interests • Governors are also required to submit declarations of interest and if they have

none to subject a ‘nil’ return. Attached at Appendix C is the declaration of interest form and attached at Appendix D is the updated Trust Business Conduct Policy for reference.

• Completed forms should be sent into the Company Secretary by 31 August

2020.

Given current circumstances with virtual working Governors who are able to do so are asked to submit the forms with electronic signatures included, and if unable to do so to provide an email confirming the attached form is submitted, as if signed. This will be appended to the form for the records and signed forms will be obtained at a


of 13

later date. Sponsor (Executive Lead):

Deborah Lawrenson

Author:

Deborah Lawrenson. Trust Secretary

Author contact details:

[email protected]


BAF 1.3


CQC requirements

Link to Relevant CQC Domain: Safe Effective Caring Responsive Well Led Link to relevant Corporate Objectives/strategic aims:

Well Led - We will empower our people to deliver

Document previously considered by: NA Recommendations: The Governors are asked to note the updated Governors Protocol in respect of the Fit and Proper Persons Test and Declarations of Interest. Governors are asked to provide completed forms directly to the Trust Secretary by 31 August 2020.


of 13

Governance Update

Council of Governors 4 August 2020

1. Introduction

All Trust Board Directors, those who perform the functions equivalent to the functions of a Board Director and Governors are subject to the Fit and Proper Persons Test. The Trust Constitution outlines requirements in respect of disqualification and removal of Governors. This protocol outlines the details of this and the process followed for confirming compliance with the Fit and Proper Persons Test (FPPT) for Governors in line with national requirements. The Trust will regularly review the ongoing fitness of Governors and will undertake the review also for all new appointees.

2. Fit and Proper Persons Test process

The Trust will carry out the following searches in respect of Governors when appointed and annually thereafter after receipt of completed Fit and Proper Persons Test forms and will undertake the following checks:

• Disqualified directors • Bankruptcy and insolvency • Removed Charity Trustees • A web search of the individual • In the case of staff governors or clinicians the following searches will be

undertaken o Nursing & Midwifery Council (NMC) o General Medical Council (GMC) o General Dental Council (GDC) o Health and Care Professions Council (HCPC) o General Pharmaceutical Council (GPhC)

While the Trust will have regard to information on when convictions, bankruptcies or similar matters are considered ‘spent’ there is no time limit for considering serious misconduct or responsibility for failure in a previous role.

The Trust Secretary will hold a personal file for each Governor that will contain a record of these pre-appointment and annual checks.

3. Disqualification and Removal of Governors

3.1 Extract from the Constitution 14. Council of Governors – disqualification and removal

14.1 The following may not become or continue as a member of the Council

of Governors:


of 13

14.1.1 A person who has been adjudged bankrupt or whose estate has been sequestrated and (in either case) has not been discharged;

14.1.2 A person who has made a composition or arrangement with or granted

a trust deed for his creditors and has not been discharged in respect of it;

14.1.3 A person who within the preceding five years has been convicted in the

British Islands of any offence if a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on him.

14.2 Governors must be at least 18 years of age at the date they are

nominated for election or appointment.

14.3 Further provisions as to the circumstances in which an individual may not become or continue as a member of the Council of Governors are set out in Annex 6.

14.4 Provisions for the removal of a governor from the Council of Governors

are set out in Annex 6. 3.2 Removal

A governor may be removed from the Council of Governors by a resolution approved by not less than two-thirds of the remaining governors present and voting on the grounds that:

o he has committed a serious breach of the code of conduct; or

o he has acted in a manner detrimental to the interests of the

Trust; and/or

o the Council of Governors consider that it is not in the best interest of the Trust for him to continue as a governor.

3.3 Annex 6 of the Constitution – Additional Provisions Council of Governors

Membership of the Council of Governors 1. The following may not become or continue as a member of the Council of

Governors:

(a) a director of the Trust;

(b) A person who has been adjudged bankrupt or whose estate has been sequestrated and (in either case) has not been discharged;

(c) A person who has made a composition or arrangement with, or granted a

trust deed for, his creditors and has not been discharged in respect of it;

(d) A person who within the preceding five years has been convicted in the British Islands of any offence if a sentence of imprisonment (whether


of 13

suspended or not) for a period of not less than three months (without the option of a fine) was imposed on him;

(e) A person who is the subject of an unexpired disqualification order

made under the Company Directors Disqualification Act 1986;

(f) a governor or director of another NHS trust or foundation trust;

(g) a spouse, partner, parent or child of a member of the Board of Directors of the Trust;

(h) being a member of the Public Constituency, a person who refuses to sign a

declaration in the form specified by the Secretary of particulars of their qualification to vote as a member of the Trust and that they are not prevented from being a member of the Council of Governors;

(i) a vexatious complainant;

(j) a person who is required to notify the police of his name and address as a

result of being convicted or cautioned for relevant sex offences pursuant to the Sex Offenders' Act 1997 or other relevant legislation;

(k) a person who has been disqualified from being a member of a relevant

authority under the provisions of the Local Government Act 2000;

(l) a person who, on the basis of disclosures obtained through an application to the Criminal Records Bureau, is considered unsuitable by the Trust’s Board of Directors;

(m) a person who within the preceding two years has been dismissed,

otherwise than by reason of redundancy, from any paid employment with a health service (whether National Health Service, private or independent care commissioner or provider) body;

(n) a person whose tenure of office as the chair or as a member or director of a

health service body has been terminated on the grounds that his appointment is not in the interests of the health service, or for non- attendance at meetings, or for non-disclosure of a pecuniary interest;

(o) he has refused without reasonable cause to undertake any training

which the Chair requires all governors to undertake; or

(p) he has failed to sign and deliver to the Secretary a statement in the form required by the Secretary confirming acceptance of the code of conduct for Governors.

Any member of the Council of Governors, or prospective member as the case shall be, shall notify the Secretary of any bar to his membership of the Council of Governors under the above paragraphs of this Annex as soon as becoming aware of such a bar. The Board of Directors may exercise its discretion to allow any individual to become or continue as a member of the Council of Governors in respect of any matter that would otherwise bar such membership under paragraphs 1(f) or 1(n) of this Annex where there is no conflict or potential conflict


of 13

of interest on the part of the governor.

4 Conflicts of Interests 4.1 Governors are required to submit signed declaration of interest forms in line with this

protocol and in reference to the Trust Business Conduct Policy which has been provided at Appendix D for guidance.

Extract from the Constitution

19. Council of Governors – conflicts of interest of governors

If a governor has a pecuniary, personal or family interest, whether that interest is actual or potential and whether that interest is direct or indirect, in any proposed contract or other matter which is under consideration or is to be considered by the Council of Governors, the governor shall disclose that interest to the members of the Council of Governors as soon as he becomes aware of it. The Standing Orders for the Council of Governors shall make provision for the disclosure of interests and arrangements for the exclusion of a governor declaring any interest from any discussion or consideration of the matter in respect of which an interest has been disclosed.


of 13

Appendix A Fit and Proper Person Checklist

Fit and Proper Persons Test (FPPT) – Checklist This checklist must be completed for all individuals within the scope of the Trust’s FPPT procedure, for both new and existing appointments. The checklist will be revalidated on an annual basis generally every April (by the Trust Secretary) and filed in the personal file for the relevant individual. Name ……………………………………………………………………………………………. Position ………………………………………………………………………………………….. Appointment Start Date ………………………………………………………………………...

Checklist completed by:

Date:

Checklist signed off by:

Date:

Comments:


of 13

Identification Checks Yes

No

Date Checked

Appendix

Verification of ID as per the right to work checklist NHS employment standards

Confirmation of any restrictions on right to work in the UK – if applicable verification of Identification and Right to Work Checklist

Confirm documents seen and that copies have been taken and verified

Professional Registration (only applicable if the person is a staff governor or a clinician - where relevant) Evidence of professional registration checked at initial appointment ( e.g. Nursing midwifery, medical)

State the professional body and details of registration.

• Register of Nursing & Midwifery https://www.nmc.org.uk/registration/search-the-register

• Register of Medical Council Register http://www.gmc-uk.org/doctors/register/LRMP.asp

• Register for Dental Council https://olr.gdc-uk.org/SearchRegister

• Register for Health and Care Professions Council http://www.hcpc-uk.org/check

• Register for General Pharmaceutical Council http://www.pharmacyregulation.org/theregister/index.aspx

Fit and Proper Persons Checks Declaration form received and confirmation of no cause for concern

If there is any cause for concern confirm outcome after discussion with the Chair and / or the Trust Secretary

Confirm check against the ‘barred ‘ list by using the register of disqualified directors, the bankruptcy /


https://www.nmc.org.uk/registration/search-the-register

https://www.nmc.org.uk/registration/search-the-register

http://www.gmc-uk.org/doctors/register/LRMP.asp

https://olr.gdc-uk.org/SearchRegister

http://www.hcpc-uk.org/check

http://www.pharmacyregulation.org/theregister/index.aspx

http://www.pharmacyregulation.org/theregister/index.aspx

of 13

insolvency register and the register of removed charities trustees:

• Disqualified directors http://wck2.companieshouse.gov.uk//dirsec

• Bankruptcy and insolvency https://www.insolvencydirect.bis.gov.uk/eiir

• Removed Charity Trustees https://www.charitycommissionni.org.uk/start-up-a-charity/register-of-removed-trustees

Internet search for evidence of vexatious behaviour


http://wck2.companieshouse.gov.uk/dirsec

https://www.insolvencydirect.bis.gov.uk/eiir

https://www.charitycommissionni.org.uk/start-up-a-charity/register-of-removed-trustees

https://www.charitycommissionni.org.uk/start-up-a-charity/register-of-removed-trustees

of 13

Appendix B

THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST (“the Trust”)

“FIT AND PROPER PERSON” DECLARATION 1. It is a condition of appointment as a Governor, that Governors provide confirmation in

writing, on appointment and thereafter on demand, of their fitness to hold such posts. Your post has been designated as being such a post. Fitness to hold such a post is determined in a number of ways, including (but not exclusively) by the Trust’s provider licence, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2008 (“the Regulated Activities Regulations”) and the Trust’s constitution.

2. By signing the declaration below, you are confirming that you do not fall within the

definition of an “unfit person” or any other criteria set out below, and that you are not aware of any pending proceedings or matters which may call such a declaration into question.

Trust’s constitution 3. The Trust’s constitution places a number of restrictions on an individual’s ability to

become or continue as a Governor. A person may not become or continue as a Governor of the Trust if:

14.5 The following may not become or continue as a member of the Council

of Governors:

14.5.1 A person who has been adjudged bankrupt or whose estate has been sequestrated and (in either case) has not been discharged;

14.5.2 A person who has made a composition or arrangement with or granted

a trust deed for his creditors and has not been discharged in respect of it;

14.5.3 A person who within the preceding five years has been convicted in the

British Islands of any offence if a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on him.

14.6 Governors must be at least 18 years of age at the date they are

nominated for election or appointment.

14.7 Further provisions as to the circumstances in which an individual may not


of 13

become or continue as a member of the Council of Governors are set out in Annex 6.

14.8 Provisions for the removal of a governor from the Council of Governors

are set out in Annex 6.

Removal

A governor may be removed from the Council of Governors by a resolution approved by not less than two-thirds of the remaining governors present and voting on the grounds that:

o he has committed a serious breach of the code of conduct; or

o he has acted in a manner detrimental to the interests of the

Trust; and/or

o the Council of Governors consider that it is not in the best interest of the Trust for him to continue as a governor.

4. Annex 6 of the Constitution – Additional Provisions Council of Governors

Membership of the Council of Governors

The following may not become or continue as a member of the Council of Governors:

a. a director of the Trust;

b. A person who has been adjudged bankrupt or whose estate has been

sequestrated and (in either case) has not been discharged;

c. A person who has made a composition or arrangement with, or granted a trust deed for, his creditors and has not been discharged in respect of it;

d. A person who within the preceding five years has been convicted in the

British Islands of any offence if a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on him;

e. A person who is the subject of an unexpired disqualification order

made under the Company Directors Disqualification Act 1986;

f. a governor or director of another NHS trust or foundation trust;

g. a spouse, partner, parent or child of a member of the Board of Directors of the Trust;

h. being a member of the Public Constituency, a person who refuses to sign a

declaration in the form specified by the Secretary of particulars of their qualification to vote as a member of the Trust and that they are not prevented from being a member of the Council of Governors;


of 13

i. a vexatious complainant;

j. a person who is required to notify the police of his name and address as a result of being convicted or cautioned for relevant sex offences pursuant to the Sex Offenders' Act 1997 or other relevant legislation;

k. a person who has been disqualified from being a member of a relevant

authority under the provisions of the Local Government Act 2000;

l. a person who, on the basis of disclosures obtained through an application to the Criminal Records Bureau, is considered unsuitable by the Trust’s Board of Directors;

m. a person who within the preceding two years has been dismissed,

otherwise than by reason of redundancy, from any paid employment with a health service (whether National Health Service, private or independent care commissioner or provider) body;

n. a person whose tenure of office as the chair or as a member or director of

a health service body has been terminated on the grounds that his appointment is not in the interests of the health service, or for non- attendance at meetings, or for non-disclosure of a pecuniary interest;

o. he has refused without reasonable cause to undertake any training

which the Chair requires all governors to undertake; or

p. he has failed to sign and deliver to the Secretary a statement in the form required by the Secretary confirming acceptance of the code of conduct for Governors.

Any member of the Council of Governors, or prospective member as the case shall be, shall notify the Secretary of any bar to his membership of the Council of Governors under the above paragraphs of this Annex as soon as becoming aware of such a bar. The Board of Directors may exercise its discretion to allow any individual to become or continue as a member of the Council of Governors in respect of any matter that would otherwise bar such membership under paragraphs 1(f) or 1(n) of this Annex where there is no conflict or potential conflict of interest on the part of the governor.

I acknowledge the extracts from the provider licence, Regulated Activities Regulations and the Trust’s constitution above. I confirm that I do not fit within the definition of an “unfit person” as listed above and that there are no other grounds under which I would be ineligible to continue in post. I undertake to notify the Trust Secretary immediately if I no longer satisfy the criteria to be a “fit and proper person” or other grounds under which I would be ineligible to continue in post come to my attention. Name: ___________________________________


of 13

Signed: ___________________________________ Position: ___________________________________ Date: ___________________________________


APPENDIX 3 Declarations of Interest(s) and amendments to declarations of interest previously declared. This form should be completed by staff where their personal interests could constitute a conflict of

interest. Certain staff are required to make an annual return as outlined in the Standards of Business

Conduct and Conflicts of Interest Policy. Name

Job Title

Department / Directorate

Declaration I have None / The following interests to declare (delete as appropriate)

Signed

Date Email and extension number

Nature and detail of your interest

Nature of Interest

Detail (including any action taken to mitigate against the conflict of interest)

Effective from

(date)

Effective to

(date)

1 Directorship (including non-executive directorships held in private companies or plc)

2 Ownership or part-ownership of private companies, partnerships, business or consultancies doing business with the NHS

3

Majority or controlling shareholdings in organisations doing business or likely or possibly seeking to do business with the NHS.

4 Position of authority in a charity or voluntary body in the field of health or social care

5 Any material connection with a voluntary or other body contracting for services with NHS organisations


6

Any material connections with an organisation or company entering into, or having entered into, a financial arrangement with the Trust

7 Financial interest in a care home or hostel

8 Any of the above held by a partner or close relative

9 Additional paid employment with another organisation where this represents a potential conflict of interest*

10

Private Practice include where you practice (name of private facility) What you practise (specialty, major procedures). When you practice (identified sessions/time commitment)

11 Other relevant interests

Approved (Line manager) Date

Name Job title

NB - Managers are reminded to seek advice as per the policy to manage possible conflicts and take the appropriate course of action where necessary Any declaration of additional paid employment with another organisation where this could be potential conflict of interest must be countersigned by an Executive Director: Potential Sanctions Staff who fail to disclose any relevant interests or who otherwise breach an organisation’s rules and policies relating to the management of conflicts of interest maybe subject to investigation and, where appropriate, to disciplinary action. The organisation may consider reporting statutorily regulated healthcare professionals to their regulator where required. Failure to manage conflicts of interest could lead to criminal proceedings including offences such as fraud bribery and corruption. In extreme cases staff could face personal civil liability.

Please return completed form to the Corporate Management Office or via email to:

[email protected]


If this form is submitted via email by your line manager, provided that it is sent from their NHS or other recognised email account, a signature may not be required.

As per the Managing Conflicts of Interest in the NHS Guidance (June 2017) Organisations are required to publish the interests of decision making staff annually on the internet, in exceptional circumstances, an individual’s name and/or other information to be redacted from any publicly available registers where the public disclosure of information could give rise to a real risk of harm or is prohibited by law. Staff who are subject to transparency initiatives such as the ABPI Disclosure UK scheme: http://www.abpi.org.uk/our-work/disclosure/Pages/disclosure.aspx should ensure they are aware and comply with them.


APPENDIX 4 Declaration of Hospitality / Sponsorship / Gifts

This form must be completed in accordance with the Standards of Business Conduct and Conflicts of Interest Policy prior to the offer being accepted. Gifts under a value of £25 - may be accepted and need not be declared. Of a value between £25 and £75 - may be accepted and must be declared using this form and countersigned by the line manager. Values of £75 or over - should be refused unless (in exceptional circumstances) approval is given by an Executive Director. A clear reason should be recorded on an organisation’s register(s) of interest as to why it was permissible to accept using this form

Name

Job Title


Declaration The following interests to declare (delete as appropriate)

Signed

Date

Email and extension number

Signed

Details of the gift* / hospitality* / sponsorship* offered * delete as appropriate

Name of organisation making the offer and relationship to the staff member and Trust (in case of an individual simply state whether a patient or relative)

Estimated value

Date offer made

In the case of hospitality / sponsorship date of event * delete as appropriate

Was prior approval or advice sought, if so, provide name, job title and date of person giving approval


Was offer accepted YES* / NO* (delete as appropriate)

Reason the offer was accepted or refused

Action taken if the offer was refused

REVIEW BY LINE MANAGER

I have reviewed the above gift* / hospitality* / sponsorship*and consider that the offer can be accepted* / should be declined* (delete as appropriate) (insert reasons)

Signed

Date

Name

Job Title

In the following cases approval is also required from an Executive Director:

• Gifts from an individual exceeding £50 in value


• Sponsorship to attend an event overseas REVIEW BY EXECUTIVE DIRECTOR

I have reviewed the above gift* / hospitality* / sponsorship*and consider that the offer can be accepted* / should be declined* (delete as appropriate) (insert reasons) Signed Date Name Job Title


[email protected]


As per the Managing Conflicts of Interest in the NHS Guidance (June 2017) Organisations are required to publish the interests of decision making staff annually on the internet, in exceptional circumstances, an individual’s name and/or other information to be redacted

from any publicly available registers where the public disclosure of information could give rise to a real risk of harm or is prohibited by law.


Standards of Business Conduct and Conflicts of Interest Policy Version: 5.1 Policy Author: Head of Financial Governance (Created 05/2017 – Disposal Date: 05/2042) Page 1 of 46

Standards of Business Conduct and Conflicts of Interest Policy

Policy Number: 54 Version: 5.1 Category: Finance Authorisation Committee: Audit and Risk Committee Date of Authorisation: 25th May 2017 Ratification Committee: Audit and Risk Committee Date of Ratification 15 October 2018 (Minor Amendments) Author name and Job title: Jonathan Ware,

Head of Financial Services Sponsor name and Job title: David Meikle,

Interim Director of Finance

Date issued: 17 October 2018 Next version date: 9 July 2020 (Approved at Audit and Risk

Committee) Review period (1, year, 2 year etc.): 3 years Scope All Trust Staff This policy has been Equality Impact Assessed

Yes

Uncontrolled once printed.

It is your responsibility to check against the intranet that this printout is the most recent version of this document.



Record of changes to this document Version

& Section Number

Amendment

Date of Change

Change/ Addition Reason

Whole document

Revision of provisions relating to what gifts, hospitality and sponsorship can be accepted and the approvals required. Revised declaration forms.

September 2013

Updated policy template and amendments in light of review of other Trusts

Appendix 4 Declaration for nil return added Septem

ber 2015 Change To make the form easier to complete

Whole document Revised to reflect new guidance April

2017 Change

NHS England Guidance – Managing Conflicts of Interest in the NHS Ref: 06419

V5.1 Appendix 3

Added a potential sanctions section. Additional sentence regarding publication of register on the Trust website

October 2018 Addition Recommendation from

ARC

Whole document

Revised to reflect new guidance and clarification of terminology

July 2020 Change Updated guidance

including GDPR

Dissemination and Consultation with Stakeholders

Disseminated to (either directly or via meetings, etc.)

Position of Stakeholder or Name of Endorsing Committee

Format (paper or

electronic) Date

Matthew Tattersall Finance Director Electronic May 2017 Michael Simms Trust Secretary Electronic May 2017 Ritu Sharma Information Governance Manager Electronic May 2017 Nicole McLaughlin Counter Fraud Specialist Electronic April / May 2020 Jonathan Ware Head of Financial Services Electronic April / May 2020 Andrew Caunce Chief Pharmacist Electronic April / May 2020 Cathy Cale Medical Director Electronic April / May 2020 Charles Medley KPMG (Internal Auditor) Electronic April / May 2020 David Meikle Interim Director of Finance Electronic April/May 2020 Deborah Lawrenson

Trust Secretary Electronic May 2020

Executive Team Executive Team Electronic May 2020 Audit and Risk Committee Electronic July 2020 for

approval



STANDARDS OF BUSINESS CONDUCT AND CONFLICTS OF INTEREST POLICY 1. All staff must be aware of this policy and adhere to it. 2. A copy of the policy will be held on the intranet and website and updated, as

necessary. 3. Line managers must read and understand the policy and ensure it is applied in their

area. 4. General Managers, Ward Managers, Heads of Service, Clinical Directors,

Consultants, Directorate Senior Nurses and Executive and Non-Executive Directors must have a good working knowledge of the policy and follow it.

5. Awareness of this policy should be included in departmental specific induction

programmes and departmental meetings.



In developing this policy, the following legislation and guidance has been duly considered: General Data Protection Regulation (GDPR) 2018 The GDPR came into effect in the UK on 25 May 2018. The General Data Protection Regulation (EU) 2016/679 (GDPR) is a regulation in EU law on data protection and privacy in the European Union (EU) and the European Economic Area (EEA). Superseding the Data Protection Directive 95/46/EC, the regulation contains provisions and requirements related to the processing of personal data of individuals (formally called data subjects in the GDPR) who reside in the EEA, and applies to any enterprise regardless of its location and the data subjects' citizenship or residence—that is processing the personal information of data subjects inside the EEA.

Diversity Policies Equality issues have been considered with regards to this policy. Adherence to this policy will therefore ensure compliance with Equalities legislation and internal Equality, Diversity and Human Rights policy.

Freedom of Information Act 2000 Freedom of Information issues have been considered with regards to this policy. Adherence to this policy will therefore ensure compliance with the Freedom of Information Act 2000 legislation and internal Freedom of Information policies.

Bribery Act 2010 The Bribery Act 2010 issues have been considered with regards to this policy. Adherence to this policy will therefore ensure compliance with the Bribery Act 2010 legislation. Health and Safety Act 1974 Health and Safety issues have been considered with regards to this policy. Adherence to this policy will therefore ensure compliance with Health and Safety legislation and internal Health and Safety policies.

Human Rights Act 1998 The Human Rights Act 1998 has been considered with regards to this policy. Proportionality has been identified as the key to Human Rights compliance. This means striking a fair balance between the rights of the individuals and those of the rest of the community. There must be a reasonable relationship between the aim to be achieved and the means used.

The Equality Act 2010 Section 149 – Public sector equality duty requires public authorise to have due regard to the needs to:

• Eliminate discrimination, harassment and victimisation • Advance equality of opportunity between people who share a characteristic and those who

do not • Foster good relations between people who share a characteristic and those who do not.

NHS England Guidance – Managing Conflicts of Interest in the NHS Ref: 06419 Conflict of interest issues have been considered with regards to this policy Adherence to this policy will therefore ensure compliance with the NHS England Guidance.



Contents 1. Operational Summary ....................................................................................................... 7

2. Introduction: overall scope and applicability of policy ........................................................ 8

3. Guiding principles ............................................................................................................. 8

4. Key terms ......................................................................................................................... 9

5. Interests ............................................................................................................................ 9

6. Staff ................................................................................................................................ 10

7. Decision Making Staff ..................................................................................................... 10

8. Identification, Declaration and Review of Interests ......................................................... 10

9. Publication ...................................................................................................................... 11

10. Interests Requiring Declaration for the Register .......................................................... 12

11. Management of Interests - General ............................................................................. 14

12. Management of Interests – Decision Making Committees and Groups ....................... 15

13. Procurement ................................................................................................................ 16

14. Gifts, loans, sponsorship, hospitality and benefits ....................................................... 16

15. Rewards for initiative ................................................................................................... 21

16. Disclosure of confidential information .......................................................................... 21

17. Use of Trust Resources ............................................................................................... 22

18. Ownership, Roles and Responsibilities ....................................................................... 22

19. Breaches: Reporting, Investigation, Outcomes and Learning ..................................... 24

20. Further guidance ......................................................................................................... 26

21. Implementation ............................................................................................................ 26

22. NHS Constitution ......................................................................................................... 26

23. Equality Impact Assessment ....................................................................................... 26

24. Dissemination of this Policy ....................................................................................... 266

25. Monitoring Compliance with this Policy ..................................................................... 287

26. References ................................................................................................................ 298

27. Explanation of Terms and Definitions ........................................................................ 298

APPENDIX 1 Ethical Code .................................................................................................... 30

APPENDIX 2 Short Guide for Staff ........................................................................................ 31

APPENDIX 3 Declarations of Interest(s) and amendments to declarations of interest previously declared. ............................................................................................................. 332

APPENDIX 4 Declaration of Hospitality / Sponsorship / Gifts .............................................. 376

APPENDIX 5 Equality Impact Assessment (EIA) Initial Screening Tool ................................ 41

APPENDIX 6 Checklist for the review and ratification of Trust Policy Documents ................. 44



1. Operational Summary Policy Aim

The aim of this policy is to help Trust staff and those who work with the Trust to understand what is expected of them in terms of standards of behaviour in conducting Trust business. The policy aims to ensure that the Trust is honest and impartial in the conduct of its business. Implementing the policy will help protect staff from any suspicion of corruption and protect the reputation of the Trust. Policy Summary The policy provides a framework for the standards of business conduct expected of staff. These standards are underpinned by the requirements of the national guidance contained in HSG (93) 5 ‘Standards of Business Conduct for NHS Staff’ and statute – the Bribery Act 2010 (which superseded the ‘Prevention of Corruption Acts 1906 and 1916 contained within this HSG). What it means for staff All Trust Employees are responsible for reading the most up-to-date version of policies to maintain current awareness of changes which impact on their roles. This policy is relevant to everyone who is employed by the Trust or is an unpaid volunteer so that they are aware of what is expected of them. The policy applies to Non-Executive Directors of the Board, Governors and staff on honorary contracts.

Staff are expected to comply with the policy and ensure that they:

• Declare conflicts that may arise between their NHS work and their personal interests. • Declare all private practice on appointment and/ or any new private practice when it

arises. • Abide by the rules regarding the acceptance of gifts, hospitality and sponsorship; and • Inform the Finance Director if they suspect that they have been offered a gift or

hospitality with corrupt intent. Staff must not:

• Abuse their official position for personal gain or to benefit their family or friends. • Misuse any financial procedures of the Trust for personal gain. • Remove items of Trust property without authorisation; or • Seek to gain advantage or further private or business interests in the course of official

duties.

Executive Directors, other Directors and divisional managers and equivalent staff will have responsibility for implementing the policy and ensuring that all staff under their direction are made aware of the policy. Those departments involved in aspects of procurement will be asked to draw its content to the attention of suppliers where appropriate and applicable.



2. Introduction: overall scope and applicability of policy 2.1 The Trust is a public body and has a duty to ensure that all its business dealings are

conducted to the highest standards of openness, honesty and transparency and public funds are properly safeguarded. This policy on Standards of Business Conduct and Conflicts of Interest has been prepared in line with the national guidance contained in HSG (93) 5 ‘Standards of Business Conduct for NHS Staff’, (within this HSG, the Bribery Act 2010 replaces the ‘Prevention of Corruption Acts ‘1889 - 1916’) the Bribery Act 2010, the NHS Code of Conduct, the Code of Conduct for NHS Managers and to meet the specific requirements of The Hillingdon Hospitals NHS Foundation Trust.

2.2 The Standards of Business Conduct set down in this policy must be adhered to by all

employees or unpaid volunteers of the Trust, whether whole time or part time. 2.3 This policy on Standards of Business Conduct and Conflicts of Interest should be read

in conjunction with the Trust’s Standing Financial Instructions. 2.4 The requirements of the policy will be drawn to the attention of newly appointed Trust

employees in the staff induction programme. Reminders to raise awareness on key aspects of the policy will be sent via email or otherwise at least every six months. A short guide to the policy is also available (Appendix 2). The policy and all associated declaration forms will also be made available on the intranet.

2.5 It is important to note that none of the requirements of this policy contradict or conflict

with individual employees’ rights as set out in the Trust’s Raising Concerns at Work Policy (formerly Whistleblowing Policy)

2.6 Similarly, nothing contained in this policy must be deemed as overriding the Trust’s

duties to comply with the requirements of the Freedom of Information Act 2000, or duties of confidentiality under General Data Protection Regulation (GDPR)

2.6 Where such conditions of this policy are not adhered to in reference to cases of Fraud

and Corruption, employees will be dealt with in accordance with the Trust’s Counter Fraud Policy and Response Plan. In such cases, the Trust’s Disciplinary Policy is not applicable, unless an investigation has been completed by the Trust’s Local Counter Fraud Specialist (LCFS) and the Finance Director, in consultation with the Director of People, has authorised the subsequent use of the Disciplinary Policy.

3. Guiding principles 3.1 The Hillingdon Hospitals NHS Foundation Trust is a public body subject to public

scrutiny and accountability for all of its actions. As such it has a duty to ensure:

• That all its business dealings are conducted to the highest standards of openness, honesty and probity; and

• That its employees, agents, contractors or others meet these standards when acting for the Trust either in their official capacities or when purporting to represent the Trust.

3.2 Trust staff are expected to:

• Ensure that the interests of patients remain paramount at all times. • Be impartial and honest in the conduct of their official business. • Use the public funds entrusted to them to the best advantage of the health services,

always ensuring value for money. • Ensure that they do not use their official position or information acquired in the



course of their official duties for personal gain or to benefit their family or friends. • Ensure that they do not advantage or further private business or other interests in the

course of their official duties. • Ensure that they do not use their status to promote commercial products or services;

and • Avoid potential bias resulting from sponsorship where this might impinge on their

professional judgement and impartiality. 3.3 It is the responsibility of all staff to ensure they comply with this policy. 4. Key terms 4.1 A ‘conflict of interest’ is:

“A set of circumstances by which a reasonable person would consider that an individual’s ability to apply judgement or act, in the context of delivering, commissioning, or assuring taxpayer funded health and care services is, or could be, impaired or influenced by another interest they hold.”

4.2 A conflict of interest may be:

• Actual - there is a material conflict between one or more interests • Potential – there is the possibility of a material conflict between one or more

interests in the future 4.3 Staff may hold interests for which they cannot see potential conflict. However, caution

is always advisable because others may see it differently and perceived conflicts of interest can be damaging. All interests should be declared where there is a risk of perceived improper conduct.

4.3 A “material interest” is an interest reported and which is assessed as appropriate for

inclusion in the Trust’s Register of Interests. 5. Interests 5.1 Interests fall into the following domains:

• Financial interests: Where an individual may get direct financial benefit1 from the consequences of a decision, they are involved in making.

• Non-financial professional interests:

Where an individual may obtain a non-financial professional benefit from the consequences of a decision, they are involved in making, such as increasing their professional reputation or promoting their professional career.

• Non-financial personal interests:

Where an individual may benefit personally in ways which are not directly linked to their professional career and do not give rise to a direct financial benefit, because of decisions they are involved in making in their professional career.

1 This may be a financial gain, or avoidance of a loss.



• Indirect interests:

Where an individual has a close association2 with another individual who has a financial interest, a non-financial professional interest or a non-financial personal interest and could stand to benefit from a decision they are involved in making.

6. Staff 6.1 The Trust uses the skills of many different people, all of whom are vital to the Trust’s

work. This includes people on differing employment terms, who for the purposes of this policy we refer to as ‘staff’ and are listed below:

• All salaried employees • All prospective employees – who are part-way through recruitment • Non-Executive Directors • Contractors, sub-contractors and advisors / consultants • Agency staff; and • Committee, sub-committee and advisory group members (who may not be directly

employed or engaged by the organisation) 7. Decision Making Staff 7.1 Some staff are more likely than others to have a decision-making influence on the use

of taxpayers’ money, because of the requirements of their role. These people are referred to as ‘Decision Making Staff.’

7.2 Decision making staff in the Trust are:

• Executive Directors • Non-Executive Directors • Members of the Senior Management Team • All Budget Holders • All staff under the Trust’s Operational Scheme of Delegation who authorise or

influence the procurement (or disposal) of goods or services. 7.3 There are some interests as defined in this policy which require reporting and

registering by decision making staff but not staff in general. 8. Identification, Declaration and Review of Interests 8.1 All staff should identify and declare interests as defined in this policy at the earliest

opportunity (and in any event within 28 days of an interest arising). If staff are in any doubt as to whether an interest requires reporting, they should declare it, so that it can be considered. Declarations should be made:

• On appointment with the organisation. • When staff move to a new role or their responsibilities change significantly. • At the beginning of a new project/piece of work. • As soon as circumstances change and new interests arise (for instance, in a meeting

when interests staff hold are relevant to the matters in discussion). • On request

2 A common sense approach should be applied to the term ‘close association’. Such an association might arise, depending on the circumstances, through relationships with close family members and relatives, close friends and associates, and business partners.



8.2 A form for reporting declarations under this policy is available as Appendix 3. The form gives instructions for completion and details of where it should be sent when completed.

8.3 Completed declaration forms should be returned to the Corporate Management Office

or via email to: [email protected] 8.4 On receipt, declarations will be assessed for materiality and if considered material will

be recorded on the Trust’s Register of Interests. 8.5 Advice can be obtained from the Trust’s Board Secretary, who has responsibility for

overseeing this policy or Assistant Board Secretary, who is responsible for maintaining the Trust’s Register of Interests. Queries should be sent by email to:

[email protected] 8.6 Material interests which have changed or ceased or errors in the Trust’s Register of

Interests should be advised by email, also using a declaration of interest form, to [email protected] 8.7 After expiry, a material interest will remain on register(s) for a minimum of 6 months

and a private record of historic interests will be retained for a minimum of 6 years. Interests declared by staff who have left the Trust or whose appointment by the Trust has ceased, will also remain on the register for a minimum of 6 months.

8.8 Decision Making Staff only will be required to pro-actively confirm a nil return annually

if this is applicable. Other staff do not need to submit a nil return. 9. Publication 9.1 The entire Register of Interests is a public document and will be available to the public

on request under the Freedom of Information Act. It will also be posted on the Trust’s Intranet and on the Trust’s public website.

9.2 The complete register will be submitted once per year to the Trust’s Audit and Risk

Committee. 9.3 If any staff have substantial grounds for believing that publication of their interests

should not take place as exceptional circumstances apply then they should make representations to:

[email protected] 9.4 Exceptional circumstances may include for example, where publication of information

might put a member of staff at risk of harm, whereby information may be withheld or redacted on public registers. However, this would be the exception and information will not be withheld or redacted merely because of a personal preference.

9.4 Representations made under 9.3 above will be reviewed by the Trust Secretary and a

decision made as to publication. An appeal against a decision of the Trust Secretary can be made to the Chief Executive Officer (or delegate*) and the decision of the Chief Executive Officer (or delegate*) shall be final. * The Trust Secretary may not be a delegate for this purpose.



10. Interests Requiring Declaration for the Register The following interests must be declared for the Register of Interests: 10.1 Any interest whereby a reasonable person would consider that an individual’s ability to

apply judgement or act, in the context of delivering, commissioning, or assuring taxpayer funded health and care services is, or could be, impaired or influenced by an interest that they hold.

10.2 Below are common examples of interests requiring declaration and associated

provisions. This list is comprehensive but not exhaustive. Staff are therefore advised to declare or seek clarification on any interest which may give rise to an actual or perceived conflict of interest which is not included in the list below. If in doubt, an interest should be declared. If not assessed as material it will not be entered on the Register. Advice can be sought by emailing [email protected].

10.3 Directorships or Ownership Interests Decision makers only should declare:

• Any directorship or any remunerated role held in any company of any legal construct. • Any shareholding giving a controlling interest in any company of any legal construct. • Any role in a not-for-profit company, business, partnership or consultancy which is

doing, or might be reasonably expected to do, business with their organisation. 10.4 Shareholdings

Decision makers only should declare:

• As a minimum, any shareholdings in any publicly listed, private or not-for-profit company, business, partnership or consultancy which a staff member knows is doing, or might be reasonably expected to do, business with the Trust.

• A declaration requires a description of the nature of the shareholding (and dates) but does not require a value or quantity of shareholding. (Unless giving a controlling interest – see under 10.3 above). e.g. a declaration of “ordinary shares in XYZ plc” is sufficient.

• There is no need to declare shares or securities held in collective investment or pension funds or units of authorised unit trusts.

• Where shareholdings are declared and give rise to risk of conflicts of interest then the general management actions outlined in this policy will be applied to mitigate risks.

10.5 Loyalty Interests Decision makers only should declare where they:

• Hold a position of authority in another NHS organisation or commercial, charity, voluntary, professional, statutory or other body which could be seen to influence decisions they take in their NHS role.

• Sit on advisory groups or other paid or unpaid decision-making forums that can

influence how their organisation spends taxpayers’ money.



• Are, or could be, involved in the recruitment or management of close family members and relatives, close friends and associates, and business partners.

• Are aware that their organisation does business with an organisation with whom close family members and relatives, close friends and associates, and business partners have decision making responsibilities.

Where holding loyalty interests gives rise to a conflict of interest then the general management actions outlined in this policy will be considered and applied to mitigate risks. 10.6 Outside Employment All staff must declare:

• any existing outside employment on appointment and any new outside employment when it arises and giving:

• A description of the nature of the outside employment (e.g. who it is with, a

description of duties, time commitment). • Relevant dates.

• Where a risk of conflict of interest arises, the general management actions outlined in

this policy will be applied to mitigate risks.

• Staff are required to seek prior approval from their line manager to engage in outside employment. (Line managers to seek advice from the Senior Manager to whom they report through to in cases of doubt).

10.7 Clinical Private Practice All clinical staff must declare:

• All private practice, on appointment / currently existing and/or any new private practice whenever it arises including:

• where they practise (name of private facility) • what they practise (specialty, major procedures). • when they practise (identified sessions/time commitment)

Clinical staff should (unless existing contractual provisions require otherwise or unless emergency treatment for private patients is needed):

• Seek prior approval of the Trust before taking up private practice. (Staff are required to seek prior approval from their line manager to engage in clinical private practice. Line managers to seek advice from the Senior Manager to whom they report through to in cases of doubt).

• Ensure that, where there would otherwise be a conflict or potential conflict of interest, NHS commitments take precedence over private work.

• Not accept direct or indirect financial incentives from private providers other than those allowed by Competition and Markets Authority guidelines:

• Clinical staff must not initiate discussions about providing their Private Professional Services for NHS patients, nor should they ask other staff to initiate such discussions on his or her behalf.



Where clinical private practice gives rise to a conflict of interest then the general management actions outlined in this policy will be considered and applied to mitigate risks. 10.8 Patents and Other Intellectual Property All staff must declare:

• Any patents and other intellectual property rights they hold (either individually, or by virtue of their association with a commercial or other organisation), including where applications to protect have started or are ongoing, which are, or might be reasonably expected to be, related to items to be procured or used by the Trust.

Staff should seek prior permission from the Trust before entering into any agreement with bodies regarding product development, research, work on pathways, etc, where this impacts on the organisation’s own time, or uses its equipment, resources or intellectual property. Where holding of patents and other intellectual property rights give rise to a conflict of interest then the general management actions outlined in this guidance will be considered and applied to mitigate risks. 10.9 Other Interests All staff must declare:

• Any other set of circumstances not covered by ss. 11.3 - 11.8 above or the Trust’s Standards of Business Conduct Policy 1 (Gifts, Hospitality and Sponsorship) and “whereby a reasonable person would consider that an individual’s ability to apply judgement or act, in the context of delivering, commissioning, or assuring taxpayer funded health and care services is, or could be, impaired or influenced by another interest they hold.”

In cases of doubt, either advice can be obtained from the Trust Secretary in the first instance or a declaration can be made at any event, and it will be assessed as to whether it may constitute a material interest. 11. Management of Interests - General 11.1 All staff have a duty to comply with this policy and to:

• exercise due diligence in reporting and updating interests • keep their line manager appraised of interests reported or possible / emerging

interests • Seek advice as provide for under this policy and as may be necessary • declare them verbally at appropriate junctures (see xx below) • take such actions as they consider appropriate in order to mitigate risks to the Trust

and to protect themselves from false allegations or perceptions 11.2 Staff are advised that in addition to declaring any material interests to the Trust, they

may also need to declare their employment or relationship with the Trust to other parties as part of that parties arrangements for managing conflicts of interests.

11.3 If an interest is declared but there is no risk of a conflict arising then no action is

warranted. However, if a material interest is declared then general management actions that could be applied may include:



• restricting staff involvement in associated discussions and excluding them from

decision making • removing staff from the whole decision-making process • removing staff responsibility for an entire area of work • removing staff from their role altogether if they are unable to operate effectively in it

because the conflict is so significant 11.4 Line managers are responsible for the determination of decisions under 11.3 above

and for communication of decisions to staff concerned. Both Line managers and staff should maintain a written audit trail of information considered and actions taken.

11.5 If necessary, line managers may seek advice from an appropriate and relevant senior

manager(s) as outlined in this policy. 11.6 In any dispute which cannot be settled at line management / senior management level,

the relevant executive director shall make the final determination. If following a director’s determination, a member of staff feels that they have not been treated fairly in respect of conflict of interests, then they may resort to the Trust’s grievance procedure.

12. Management of Interests – Decision Making Committees and Groups 12.1 The Trust uses a variety of different committees and groups to make key strategic

decisions, decisions which involve spending taxpayers money or whereby a member of that committee or group may be in a position to influence a decision which may give rise to a conflict of interest.

12.2 A Decision-Making Committee or Group for the purposes of this section is:

(i) Any committee or group which is identified on the Trust’s committee structure and which has formal terms of reference and

(ii) Any working group, steering group or collective group by any name which is established by a committee or group as defined by (i) above.

12.3 Groups as defined in this section must adopt the following principles:

(i) “Declaration of Interests in Agenda Items” should be a standing agenda item for all meetings and be listed immediately after any special announcements, welcomes / apologies for absence and before items of formal business.

(ii) Calling for declarations is the responsibility of the chair of the meeting.

(iii) Members should take personal responsibility for declaring material interests either:

• In advance of a meeting and on receipt of the agenda if the perceived conflict as already declared for the Trust’s Register of Interests negates the value of attendance for the entire meeting. (In which case declaration should be made in advance to the Chair) or

• At the beginning of each meeting or • Should any unforeseen conflicts of interest arise during the course of the meeting.

(iv) Any interests identified and declared during the course of the meeting must be

recorded in the minutes / notes of the meeting and if deemed material by the Chair of



the meeting a declaration must be made for inclusion in the Trust’s register of interests in accordance with this policy if this has not already been done.

(v) The vice chair (or another non-conflicted member) should chair all or part of a meeting if the chair has an interest that may prejudice their judgement.

(vi) If a member declares an actual or potential interest the chair should consider any of

the following approaches as assessed as appropriate and ensure that the reason for the chosen action is documented in minutes or records:

• Requiring the member to not attend the meeting. • Excluding the member from receiving meeting papers relating to their interest. • Excluding the member from all or part of the relevant discussion and decision. • Noting the nature and extent of the interest but judging it appropriate to allow the

member to remain and participate. • Removing the member from the group or process altogether.

(vii) (The default response should not always be to exclude members with interests, as

this may have a detrimental effect on the quality of the decision being made. Good judgement is required to ensure proportionate management of risk.

13. Procurement 13.1 Procurement should be managed in an open and transparent manner, compliant with

procurement and other relevant law, to ensure there is no discrimination against or in favour of any provider. Procurement processes should be conducted in a manner that does not constitute anti-competitive behaviour - which is against the interest of patients and the public.

13.2 Those involved in procurement exercises for and on behalf of the Trust should keep

records that show a clear audit trail of how conflicts of interest have been identified and managed as part of procurement processes. At every stage of procurement steps should be taken to identify and manage conflicts of interest to ensure and to protect the integrity of the process.

14. Gifts, loans, sponsorship, hospitality and benefits 14.1 Overview of legal position All employees of The Hillingdon Hospitals NHS Foundation Trust are required to

exercise high standards of honesty and probity in the course of all their dealings on behalf of the Trust in order to avoid corrupt practice. Additional requirements are also placed on them by the Bribery Act 2010 as detailed below.

The Bribery Act 2010 replaces the fragmented and complex offences at common law and in the Prevention of Corruption Acts 1889-1916. This broadly defines the sections below:

• Two general offences of bribery – 1) Offering or giving a bribe to induce someone to behave, or to reward someone for behaving, improperly and 2) requesting or accepting a bribe either in exchange for acting improperly, or where the request or acceptance is itself improper;

• The new corporate offence of negligently failing by a company or limited liability partnership to prevent bribery being given or offered by an employee or agent



on behalf of that organisation. Bribing a foreign official. If staff have a personal, financial or other problem, they may be more vulnerable to

offers of inducement than they would otherwise be. The Trust’s Employee Assistance Programme allows access to independent counselling to support staff. It is in the employee’s best interests to discuss such matters in confidence with their manager when such a problem is identified, both to secure assistance and advice and to avoid unwarranted suspicion.

In all circumstances, it is vital that staff adhere strictly to the following rules contained within this policy. In the event that they fail to do so, the Trust’s Staff Disciplinary Policy may be invoked and as a consequence staff may face the prospect of loss of employment and superannuation rights in the NHS, quite apart from the prospect of being exposed to criminal prosecution. It is recognised that there may be exceptional circumstances whereby exemptions may apply for example in terms of gifts and hospitality support received by staff during a level 4 emergency such as Covid-19.

14.2 Protocols for gifts, loans, sponsorship, hospitality & benefits

What staff must not accept

Other than the limited circumstances outlined in paragraph 14.5 below, the receipt of gifts, loans, sponsorship, hospitality or benefits in circumstances that provide no direct benefit to the Trust is not acceptable and should generally be refused and declared. This includes but is not limited to: • Goods or services for private use • Payments by business contacts to subsidise social events • Discounts on products (with the exception of those offered to all staff corporately) • Tickets to cultural or sporting events (with the exception of those offered to all staff

corporately) • Use of a flat or other accommodation. Staff must refuse any offer of money whether in the form of cash or cheque or vouchers; however, it is possible for such offers to be donated to the Trust’s charity. Any offer should be refused with a letter from the recipient explaining that staff are prohibited from accepting the money, but it could be donated to the charity if the donor wishes. If the donor does not agree then the money must be returned. Offers to pay travel, subsistence and related costs to Trust employees to visit premises or attend any event organised by a third party (e.g. a contractor or supplier) should be refused, unless it can be shown there is clear benefit to the Trust. Any offer must be declared whether it is accepted or refused using the form in appendix 4 and be countersigned by the line manager. Staff should also pay particular attention to the circumstances in which hospitality is offered. For example, the acceptance of hospitality from an individual or organisation on occasions listed below is never acceptable and offers must be refused and reported:

• During a related tendering exercise • Where a related contract is due to come to an end • Where the performance of a related contract is in question • ‘Linked sponsorship arrangements’ whereby external sponsorship is linked to

the procurement of goods and services



• Any other circumstances where acceptance might compromise the member of staff or the Trust.

Where staff believe an organisation has offered gifts or hospitality in expectation of something in return this must be reported to the Finance Director. This could be considered an inducement under the Bribery Act 2010. All Consultants are required to comply with the rules and procedures governing the acceptance of gifts and hospitalities as laid down in the Consultants Contract and the Terms and Conditions for Consultants for England (January 2004). Medical staff should also ensure they comply with guidance issued by the General Medical Council.

14.3 What staff need to do when they refuse a gift, loan, an offer of sponsorship or hospitality, or benefits

Any offer/gift must be returned with a letter from the recipient of the offer/gift, politely explaining that Trust employees are prohibited from accepting gifts. The offer should be declared using the form in appendix 4 and a copy of the letter attached.

14.4 What staff must not offer

Staff must not offer any gift, loan, sponsorship, hospitality or benefit to any person in relation to Trust business. Both Trust employees and those dealing on behalf of the Trust (e.g. independent advisers, contractors or consultants) are included in this prohibition.

14.5 Gifts: What staff may accept

a) Gifts from a patient or patient’s family

Staff may accept small tokens to a value of £50 (excluding money or vouchers) from patients which may be offered as a token of appreciation for the care they have received. These gifts do not need to be declared.

If a gift is offered as a ‘token of gratitude’ but is likely to have a value above £50, then the gift must be referred to an Executive Director who will decide on whether it can be accepted. These gifts whether accepted or declined must declared using the form at Appendix 4.

Where staff believe they have been offered a gift to gain preferential treatment the gift should be declined and declared. If several small gifts are given to an individual from the same source within any one year, then the matter should be referred to an Executive Director as soon as possible. b) Gifts from external organisations Staff may accept unsolicited small tokens to the value of £6 from an external organisation, this might include:

• diaries, calendars, stationery designed to advertise the organisation • A conventional personal gift such as chocolates or flowers • Work related publications.



If several small tokens are given to an individual or department from the same source within one year the matter should be referred to an Executive Director. There are occasions when it is not proper to refuse gifts, for example if the Trust deals with or forms an alliance with a foreign company or organisation where it is considered ‘cultural custom and practice’ to exchange gifts. In this situation, employees must seek guidance from the Finance or other Executive Director. c) Donations to charity

Acceptance of donations made by suppliers or bodies seeking to do business with an organisation should be treated with caution and not routinely accepted. In exceptional circumstances a donation from a supplier may be accepted but should always be declared. A clear reason should be recorded as to why it was deemed acceptable, alongside the actual or estimated value using the form in appendix 4. Staff should not actively solicit charitable donations unless this is a prescribed or expected part of their duties for an organisation or is being pursued on behalf of the Trust’s charity or other charitable body and is not for their own personal gain. Staff must obtain permission from their manager if in their professional role they intend to undertake fundraising activities on behalf of a pre-approved charitable campaign. Donations, when received, should be made to a specific charitable fund (never to an individual) and a receipt should be issued. Staff wishing to make a donation to a charitable fund in lieu of a professional fee they receive may do so, subject to ensuring that they take personal responsibility for ensuring that any tax liabilities related to such donations are properly discharged and accounted for.

14.6 Loans

Staff must refuse any offer of money whether in the form of cash or cheque or vouchers; however, it is possible for such offers to be donated to the Trust’s charity. Any offer should be refused with a letter from the recipient explaining that staff are prohibited from accepting the money, but it could be donated to the charity if the donor wishes. If the donor does not agree then the money must be returned.

14.7 Hospitality and Benefits

Hospitality accepted must be secondary to the purpose of the meeting and should only be accepted where there is a genuine link to working arrangements and a genuine business reason can be demonstrated. Some examples include:

• Attending a corporate reception/event to network • A meeting/event organised by one of the Trust’s partners to develop a sounder

working relationship • An industry function • Speaking in a professional capacity at a conference or event.

The level of hospitality offered must not give rise to inference of impropriety. It must be appropriate to the occasion; and the costs involved must not exceed that level which the recipients would normally adopt when paying for themselves or that which would be reciprocated by the Trust. As with gifts, staff are expected to use their judgement



when they are offered and accept hospitality from external organisations. They must be able to demonstrate that the appropriateness/frequency of the hospitality can be justified. Staff should not ask for or accept hospitality that may affect, or be seen to affect, their professional judgement. Hospitality must only be accepted when there is a legitimate business reason and it is proportionate to the nature and purpose of the event.

From time to time the Trust receives and passes on to staff offers of free tickets for theatres, concerts etc. These are offered in appreciation of the work of health services staff and where offered via the Trust, they may be freely accepted and not registered.

14.8 Meals and refreshments

Under a value of £25 - may be accepted and need not be declared. Of a value between £25 and £75 - may be accepted and must be declared using the form in appendix 4 and countersigned by the line manager. Over a value of £75 - should be refused unless (in exceptional circumstances) approval is given by an Executive Director. A clear reason should be recorded on an organisation’s register(s) of interest as to why it was permissible to accept using the form in Appendix 4 A common sense approach should be applied to the valuing of meals and refreshments (using an actual amount, if known, or an estimate that a reasonable person would make as to its value).

14.9 Travel and accommodation If it can be shown that there is a clear benefit to the Trust modest offers to pay some or all of the travel and accommodation costs related to attendance at events may be accepted and must be declared using the form in appendix 4 and be countersigned by the line manager. Offers which go beyond modest or are of a type that the organisation itself might not usually offer, need approval by an Executive Director, should only be accepted in exceptional circumstances, and must be declared. A clear reason should be recorded using the form in appendix 4 as to why it was permissible to accept travel and accommodation of this type.

14.10 Sponsorship

The Trust would not wish to decline appropriate offers of commercial sponsorship such as to promote the work of the Trust or where a member of staff is a speaker or delegate at a conference or academic meeting that enhances the reputation of both the individual and the Trust, or is part of the individual’s professional personal development. Staff may accept commercial sponsorship for attendance at relevant courses and conferences provided permission is obtained in advance and purchasing decisions and patient care are not compromised. Any commercial sponsorship (e.g. flights or accommodation) for an event held overseas must be approved by an Executive Director in advance. Staff who benefit from sponsorship must inform the company concerned that sponsorship will not provide them with an advantage in relation to Trust business.



Sponsorship of events by appropriate external bodies should only be approved if a reasonable person would conclude that the event will result in clear benefit for the Trust. During dealings with sponsors there must be no breach of patient or individual confidentiality or data protection rules and legislation.

No information should be supplied to the sponsor from which they could gain a commercial advantage, and information which is not in the public domain should not normally be supplied.

Staff should make it clear that sponsorship does not equate to endorsement of a company or its products but the Trust or any member of staff and this should be made visibly clear on any promotional or other materials relating to the event

Staff should declare involvement with arranging sponsored events to their organisation.

Any absence resulting from attendance at an event must be authorised in accordance with the relevant leave policy. Commercial sponsorship for a conference place, travel and accommodation is acceptable for the individual only and must not cover spouses or partners.

14.11 Commercial sponsorship of posts

Pharmaceutical or other companies may offer to sponsor, wholly or partially, a post for an employing Trust. This type of sponsorship is also offered indirectly; by way of an offer to support staff on to take a secondment, or to undertake training, either by a direct financial contribution or by the external company hosting the training course itself. The Trust will not enter into such arrangements, unless it is made abundantly clear to the company concerned that such sponsorship and/or training provision will have no effect on the decisions made for or by the Trust. Where such sponsorship is accepted, the Trust will monitor business decisions to ensure that they are not, in fact, being influenced by the sponsorship agreement. “Linked deals” whereby sponsorship is linked to the purchase of particular products, or to supply from particular sources, will not be authorised under any circumstances. All staff should familiarise themselves with the Bribery Act 2010 detailed in section 14.1.

15. Rewards for initiative

The Trust will ensure that intellectual property rights are properly protected and fully exploited. Any rewards, royalties or other benefits in respect of work commissioned from third parties, or for work carried out by employees in the course of their NHS employment, will be obtained by the Trust and employees will receive any rewards due to them. Arrangements will also be set in hand to ensure the receipt of rewards for collaborative work with manufacturers and for any rewards to be passed on to Trust employees.

16. Disclosure of confidential information 16.1 General principles

Employees should not, during the course of their employment or after its termination, use or disclose to any other person, public authority, company or institution any



confidential information relating the Trust or its activities except in pursuance of the authorised business of The Hillingdon Hospitals NHS Foundation Trust. Information, data specifications and all documents relating to the Trust’s business and personnel must be treated as confidential.

However, the term “confidential” or “commercial in confidence” should not be taken to include information about service delivery and activity levels, which should be publicly available. Nor should it inhibit the free exchange of data for clinical audit purposes, provided that the normal rules governing patient confidentiality and data protection are observed.

16.2 Internal confidentiality

It is important that confidentiality is maintained within the Trust and an appropriate level of authorisation must be obtained before any information of a confidential nature is passed to other employees who may not be authorised to receive it. In addition, it is important that, in transmitting information in a written form, care is taken to ensure that where this is of a confidential nature it is addressed correctly.

16.3 Confidentiality with external bodies The uncontrolled or premature release externally of information relating to the Trust’s business or personnel could be harmful to the Trust and not be in the best interests of patients or the public in general. Such information may be of a technical, financial, commercial or personal nature or may relate to the Trust’s plans for the future. Appropriate authorisation must, therefore, be obtained before any confidential information is released externally. Staff should not publish literature, deliver any lecture or make any communication to the press, radio or television relating to the Trust’s business or to any matters with which the Trust may be concerned, unless staff have the permission of the Chief Executive or their Executive Director.

16.4 Removal of confidential documents

Some employees may need to take home documents on which they are to work, and which relate to their job function. They are responsible for the security of these documents. The removal of any other documents relating to the work of the Trust is strictly prohibited, except with the prior authorisation of their Executive Director.

17. Use of Trust Resources

Only in exceptional circumstances, and after specific written authority from an Executive Director, may the Trust’s resources (namely property and staff) be used for private purposes.

18. Ownership, Roles and Responsibilities

Responsible Committee The Executive Team (ET) is the responsible Committee for this policy. Executive Director The Interim Director of Finance the identified Executive Director for this policy. Policy Author The identified Policy author for this policy is the Head of Financial Governance.



Executive Directors, Assistant Directors and Heads of Department Are responsible for:

• Ensuring that their staff are aware of the provisions of this policy • Countersigning declarations of hospitality or sponsorship • Acting as the first point of contact for advising their staff on the process under

this policy or on what may or may not constitute acceptability in respect of gifts, hospitality and sponsorship.

• Seeking advice from the Trust Board Secretary or Assistant Trust Board Secretary in cases of doubt on the process under this policy or on what may or may not constitute acceptability in respect of gifts, hospitality or sponsorship.

All Staff All staff and persons working on behalf of the Trust must NOT:

• Accept (or offer) any inducements or inappropriate hospitality, sponsorship or gifts • Abuse their past or present official position to obtain private benefits or advantage • Unfairly advantage one competitor over another or show favouritism in agreeing to

sponsorship All staff and persons working on behalf of the Trust MUST:

• Comply with the provisions of this policy and be open and honest in making declarations of hospitality or sponsorship as provided under this policy

• Complete and submit declarations of hospitality or sponsorship appropriately. • Seek advice from their line manager in the first instance if they have any doubts as to

the process under this policy or as to what may or may not constitute acceptability in respect of gifts, hospitality or sponsorship.

• Report any suspected breaches of this policy through normal reporting channels or through the Trust Freedom to Speak-up/ Whistleblowing Policy

• Report any suspected incidences of fraud, bribery or corruption in accordance with the Trust’s Counter Fraud and Corruption Policy by referral to the Trust’s Local Counter Fraud Specialist (LCFS). Should evidence of fraud, bribery or corruption be discovered the Trust may initiate disciplinary, criminal and civil sanctions as appropriate.

Specialist Groups/ Individuals Local Counter-Fraud Specialist (LCFS) - In line with the Trust’s Counter-Fraud Policy, the Local Counter-Fraud Specialist is responsible for investigating referrals of cases of suspected fraud, bribery or corruption. Trust Board Secretary - is accountable for:

• the process under this policy and for the maintenance of the Trust’s Register of Hospitality and Sponsorship.

• supervising, supporting and advising the Assistant Trust Secretary in the exercise of their functions under this Policy

• in cases of doubt, seeking a determination from (i) the CEO and/or Director of Finance as to what may or may not constitute acceptable or unacceptable gifts, hospitality or sponsorship or (ii) referral to the Chief Pharmacist and / or Medical Director in cases of hospitality or sponsorship offered by pharmaceutical companies or their agents and where adjudication may be required.



The Assistant Trust Board Secretary (or otherwise as delegated by the Company Secretary) is responsible for:

• Maintaining the Trust’s register of “Declarations of Hospitality and Sponsorship” on a day to day basis and

• Advising staff on process under this policy and what may constitute acceptable/ unacceptable gifts, hospitality or sponsorship. (Or in cases of doubt, referring queries to the Company Secretary)

• Making the Register publically available on request • Submitting the Register once per annum to the Trust’s Audit Committee for review.

Chief Pharmacist - is responsible for:

• Drafting and keeping updated Guidelines to support this policy as to the acceptance or otherwise of sponsorship, hospitality or gifts provided by a pharmaceutical company or their agents. (Such guidelines to consider the Association of the British Pharmaceutical Industry (ABPI) code or other relevant guidance or provisions).

• Submitting (Anonymised) Reports on breaches to the Trust’s Executive Team and Audit Committee at a frequency to be agreed or, on request by the CEO / Chair of the Audit Committee.

• Advising the Medical Director in cases where adjudication may be required as to the acceptance or otherwise of sponsorship or, hospitality or gifts provided by a pharmaceutical company or their agents.

Medical Director - is responsible for:

• Considering advice from the Chief Pharmacist and making adjudication when

necessary as to the acceptance or otherwise of sponsorship, hospitality or gifts provided by a pharmaceutical company or their agents.

Audit and Risk Committee - shall be responsible on behalf of the Board for:

• Being assured by the Executive Director and policy author that the policy is robust and effective in reducing relevant risks to the Trust and

• Annually reviewing the Register of Hospitality and Sponsorship. 19. Breaches: Reporting, Investigation, Outcomes and Learning

19.1 There will be situations when interests will not be identified, declared or managed

appropriately and effectively. This may happen innocently, accidentally, or because of the deliberate actions of staff or other organisations. For the purposes of this policy these situations are referred to as ‘breaches’. Any breach of this policy will be taken seriously and may lead to action up to and including dismissal. All staff should be aware that a breach of the provisions of the Bribery Act 2010 renders them liable to prosecution and may lead to their dismissal from employment and loss of superannuation rights in the NHS.

19.2 Staff who are aware about actual breaches of this policy, or who are concerned that

there has been, or may be, a breach, should report these concerns to the Trust Secretary. To ensure that interests are effectively managed staff are encouraged to speak up about actual or suspected breaches. Every individual has a responsibility to do this. Any actual or suspected breaches should be notified to the Finance Director Breaches will be investigated, and further action may be taken in line with the Trust’s



Disciplinary Policy and Procedure, Raising Concerns at Work Policy and Procedure and the Counter Fraud and Corruption Policy and reported, via the Trust Secretary through the Trust governance structure as outlined in 19.10.

19.3 The Trust’s Local Counter Fraud Specialist (LCFS) will investigate each reported

breach in accordance with the Counter Fraud and Corruption Policy and according to its own specific facts and merits and give relevant parties the opportunity to explain and clarify any relevant circumstances.

19.4 Following investigation the Trust will:

• Decide if there has been or is potential for a breach and if so the what severity of

the breach is. • Assess whether further action is required in response – this is likely to involve any

staff member involved and their line manager, as a minimum. • Consider who else inside and outside the organisation should be made aware • Take appropriate action as set out in the next section.

19.5 Action taken in response to breaches of this policy will be in accordance with the

disciplinary procedures of the Trust and could involve organisational leads for staff support (e.g. Human Resources), fraud (e.g. Local Counter Fraud Specialists), members of the management or executive teams and organisational auditors.

19.6 Breaches could require action in one or more of the following ways:

• Clarification or strengthening of existing policy, process and procedures. • Consideration as to whether HR/employment law/contractual action should be

taken against staff or others. • Consideration being given to escalation to external parties. This might include

referral of matters to external auditors, NHS Protect, the Police, statutory health bodies (such as NHS England, NHS Improvement or the CQC), and/or health professional regulatory bodies.

19.7 Inappropriate or ineffective management of interests can have serious implications for

the organisation and staff. There will be occasions where it is necessary to consider the imposition of sanctions for breaches.

19.8 Sanctions will not be considered until the circumstances surrounding breaches have

been properly investigated. However, if such investigations establish wrong-doing or fault then the organisation can and will consider the range of possible sanctions that are available, in a manner which is proportionate to the breach. This includes:

• Employment law action against staff, which might include

• Informal action (such as reprimand, or signposting to training and/or guidance).

• Formal disciplinary action (such as formal warning, the requirement for

additional training, re-arrangement of duties, re-deployment, demotion, or dismissal).

• Reporting incidents to the external parties described above for them to consider

what further investigations or sanctions might be.



• Contractual action, such as exercise of remedies or sanctions against the body or staff which caused the breach.

• Legal action, such as investigation and prosecution under fraud, bribery and

corruption legislation.

19.9 (Anonymised) Reports on breaches shall be submitted by the Trust Secretary to the Trust’s Executive Team and Audit Committee at a frequency to be agreed or, on request by the CEO / Chair of the Audit Committee.

19.10 To ensure that lessons are learnt, and management of interests can continually

improve, reports referred to under 13.10 above shall include consideration of the impact of breaches and actions taken / to be taken.

20. Further guidance

This policy has been prepared to set out some rules and to give guidance about its applicability. If staff are in any doubt about any matter concerning the policy, they should seek advice in the first instance from their line manager or Executive Director. Advice on the policy and its applicability can also be sought from the Finance Director.

It is important to note this policy does not replace or substitute any professional or other codes that members of staff or individuals connected with the Trust are obliged to follow. In addition, all NHS Managers are obliged to follow and adhere to the requirements of the Code of Conduct for NHS Managers. For the purpose of this policy the Trust defines a ‘manager’ as any member of staff with responsibility for managing staff, budget or other resource.

21. Implementation

Executive Directors, Assistant Directors and Heads of Department will have responsibility for the implementation of this policy. Policy revision will be the responsibility of the Finance Director. The Board will be responsible for approving major revisions to the policy. This policy and all the relevant declarations are reviewed annually by the Audit and Risk Committee. The Internal Audit and the Counter Fraud Service providers will assess compliance and any gaps will be reviewed and investigated where appropriate.

22. NHS Constitution

The Trust is committed to the principles and values of the NHS constitution and this document takes in to account these principles and values.

23. Equality Impact Assessment

The Trust is committed to promoting an environment that values diversity. The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. This document has been equality impact assessed and this can be found in Appendix 5.

24. Dissemination of this Policy

This policy document will be available to all staff via the Trust Policy Information



Management System; staff will be alerted to the policy by a standard general email.



25. Monitoring Compliance with this Policy Element to be

monitored Lead Tool / Methodology Frequency Reporting

arrangements Action Lead(s)

Change in practice and lessons to be shared

What needs Monitoring

Who will lead on this aspect of monitoring – name the lead and job title

What tool will I use to monitor/check that everything is working according to this element of the policy

How often will we need to monitor/ frequency

Who or what committee will I report the results to for information and actions

Who will undertake the action planning for deficiencies

How will changes be implemented and lessons shared

Hospitality & Gifts Register Forms

Head of Financial Governance

Review forms for accuracy and completeness

Annual Finance Director Head of Financial Governance

Required changes to practice will be identified and actioned as necessary. A member of staff will be identified to take each change forward where appropriate and lessons will be shared with all the relevant stakeholders.

Declaration of Interest Form


Review forms for accuracy and completeness

Annual Finance Director Head of Financial Governance

As above

Standards of Business Conduct and Conflicts of Interest Systems & Processes

Internal Audit (KPMG) Audit 1-2 yearly

Audit and Risk Committee (ARC)


As above



26. References

• HSG (93) 5 ‘Standards of Business Conduct for NHS Staff’ (as amended by the Bribery Act 2010)

• Trust Standing Financial Instructions

• Code of Practice for NHS Managers

• Freedom of Information Act 2000

• The Bribery Act 2010

• Policy for the Development and Management of Trustwide Policies and Strategy Documents

• Raising Concerns at Work Policy (formerly Whistleblowing Policy)

• NHS England Guidance – Managing Conflicts of Interest in the NHS Ref: 06419

• Counter Fraud Policy and Response Plan • University College London Hospitals NHS Foundation Trust – Code of Conduct and

Conflicts of Interest Policy • General Medical Council – Financial and Commercial Arrangements and conflicts of

interest 27. Explanation of Terms and Definitions

Gift An item transferred without the expectation of payment. Gifts are defined within this policy as being either (i) acceptable (and do not require declaration) or (ii) unacceptable.

Hospitality The reception and entertainment of individuals which subject to exemptions defined in this policy, requires declaration for inclusion on the Trust’s Register of Hospitality and Sponsorship.

Sponsorship

NHS funding from an external, commercial source, including but not restricted to, funding of all or part of the costs of a member of staff, NHS research, staff, training, pharmaceuticals, equipment, meeting rooms, costs associated with meetings, meals, gifts, hospitality, hotel and transport costs (including trips abroad), provision of free services (speakers), buildings or premises. Subject to exemptions defined in this policy, sponsorship requires declaration for inclusion on the Trust’s Register of Hospitality and Sponsorship. NB- Sponsorship does not include funding made available to the Trust by external, statutory agencies where such funding is made under statutory or discretionary powers.



Accountability Everything done by those who work in the NHS must be able to stand the test of parliamentary scrutiny, public judgements on propriety and professional codes of conduct.

Probity

Means that there should be an absolute standard of honesty in dealing with the assets of the NHS. Integrity should be the hallmark of all personal conduct affecting service users, employees and suppliers and in the use of information acquired in the course of NHS duties.

Openness Means that there should be sufficient transparency about NHS activities to promote confidence between the Trust and its employees, service users and the public.

Improper Performance

Under the Bribery Act 2010 improper performance is defined in summary as ‘performance which amounts to a breach of an expectation that a person will act in good faith, impartially, or in accordance with a position of Trust’. The offence applies to bribery relating to any function of a public nature, connected with a business, performed in the course of a person’s employment or performed on behalf of a company or another body of persons. Therefore, bribery in both the public and private sectors is covered by the Act. NB: It is an offence for a person to offer, promise or give a financial or other advantage to another person in one or two cases:

• Case 1 applies where that person intends the advantage to bring about the improper performance by another person of a relevant function or activity or to reward such improper performance.

• Case 2 applies where the person knows or believes that the acceptance of the advantage offered, promised or given in it constitutes the improper performance or a relevant function or activity.

Register of Hospitality and Sponsorship

A register kept by the Trust which is open to public inspection and which (i) serves to demonstrate openness and transparency and (ii) offer protection to staff and persons working on behalf of the Trust by ratifying Trust endorsement to the receipt of Hospitality and Sponsorship as deemed acceptable within the provisions of this policy.

Fraud a dishonest act deliberately practiced in order to secure unfair or unlawful gain.

Bribery the act or practice of offering, giving, or taking a bribe. See section 8.1 for the legal position and a summary of the Bribery Act (2010).

Conflict of interest

a situation in which an official's decisions are influenced by their personal interests.



APPENDIX 1 Ethical Code

Employees must always comply with the Trust’s ethical standards by:

A. Maintaining the highest possible standards of business integrity

B. Rejecting any business practice which might reasonably be deemed improper

C. Never using their authority for personal gain

D. Complying both with the letter and the spirit of the laws of the United Kingdom, the policies and procedures of the Trust and all contractual obligations that the Trust enters into.



APPENDIX 2 Short Guide for Staff

STANDARDS OF BUSINESS CONDUCT AND CONFLICTS OF INTEREST POLICY

DO: • Make sure YOU are aware that the Trust has a Standards of Business Conduct and Conflicts

of Interest Policy, and where to find a copy – on the intranet or from your line manager. • If you are responsible for any staff, make sure they are aware of the Policy, where to find a

copy, and apply it in your area. • Consult your line manager in the first instance if you are not sure about the guidance in the

Policy. • Make sure you (or your staff) are not in a position where private interests and NHS duties

may come into conflict. • Declare any relevant interests. If in doubt, ask yourself:

i) Am I, or might I be, in a position where I (or my family or friends) could gain from the

connection between my private interests and my NHS employment? ii) Do I have access to information, which could influence decisions about the purchase of

NHS goods and services? iii) Could my outside interest be in any way detrimental to the NHS or to patients’ interests? iv) Do I have any other reason to think I may be risking a conflict of interest?

If still unsure – declare it!

• Inform your line manager if you take on paid employment outside of the Trust. • Obtain advance approval from an Executive Director if you want to accept commercial

sponsorship in the circumstances permissible in this policy

• Raise any concern you may have in relation to fraud or potential bribery offences Advice can be sought by emailing [email protected]. DO NOT: • Accept any money

• Accept any gifts or other inducements or inappropriate sponsorship or hospitality (other than

what is acceptable in this policy) • Abuse previous or present official position(s) to obtain preferential rates for private deals

• Interview a close friend or relative

• Unfairly advantage one competitor over another, or show favouritism in awarding contracts * Misuse or make available official “confidential” or “commercial in confidence” information It is important to note that none of the requirements set out in the Standards of Business Conduct and Conflicts of Interest Policy contradicts or overrides individual employee rights as set out in the Raising Concerns at Work Policy (formerly Whistleblowing Policy)



APPENDIX 3 Declarations of Interest(s) and amendments to declarations of interest previously declared.

This form should be completed by staff where their personal interests could constitute a conflict of interest.

Certain staff are required to make an annual return as outlined in the Standards of Business Conduct and Conflicts of Interest Policy.

Name

Job Title


Declaration I have None / The following interests to declare (delete as appropriate)

Signed

Date

Email and extension number Nature and detail of your interest

Nature of Interest Detail (including any action taken to mitigate against the conflict of interest)

Effective from (date)

Effective to (date)

1 Directorship (including non-executive directorships held in private companies or plc)

2

Ownership or part-ownership of private companies, partnerships, business or consultancies doing business with the NHS



Nature of Interest Detail (including any action taken to mitigate against the conflict of

interest) Effective from

(date) Effective to

(date)

3

Majority or controlling shareholdings in organisations doing business or likely or possibly seeking to do business with the NHS.

4 Position of authority in a charity or voluntary body in the field of health or social care

5 Any material connection with a voluntary or other body contracting for services with NHS organisations

6

Any material connections with an organisation or company entering into, or having entered into, a financial arrangement with the Trust

7 Financial interest in a care home or hostel

8 Any of the above held by a partner or close relative

9

Additional paid employment with another organisation where this represents a potential conflict of interest*



Nature of Interest Detail (including any action taken to mitigate against the conflict of

interest) Effective from

(date) Effective to

(date)

10

Private Practice include where you practice (name of private facility) What you practise (specialty, major procedures). When you practice (identified sessions/time commitment)

11 Other relevant interests

Approved (Line manager) Date

Name Job title

NB - Managers are reminded to seek advice as per the policy to manage possible conflicts and take the appropriate course of action where necessary Any declaration of additional paid employment with another organisation where this could be potential conflict of interest must be countersigned by an Executive Director: Potential Sanctions Staff who fail to disclose any relevant interests or who otherwise breach an organisation’s rules and policies relating to the management of conflicts of interest maybe subject to investigation and, where appropriate, to disciplinary action. The organisation may consider reporting statutorily regulated



healthcare professionals to their regulator where required. Failure to manage conflicts of interest could lead to criminal proceedings including offences such as fraud bribery and corruption. In extreme cases staff could face personal civil liability.


[email protected]

If this form is submitted via email by your line manager, provided that it is sent from their NHS or other recognised email account, a

signature may not be required. As per the Managing Conflicts of Interest in the NHS Guidance (June 2017) Organisations are required to publish the interests of decision making staff annually on the internet, in exceptional circumstances, an individual’s name and/or other information to be redacted from any publicly available registers where the public disclosure of information could give rise to a real risk of harm or is prohibited by law. Staff who are subject to transparency initiatives such as the ABPI Disclosure UK scheme: http://www.abpi.org.uk/our-work/disclosure/Pages/disclosure.aspx should ensure they are aware and comply with them.



APPENDIX 4 Declaration of Hospitality / Sponsorship / Gifts

This form must be completed in accordance with the Standards of Business Conduct and Conflicts of Interest Policy prior to the offer being accepted. Gifts under a value of £25 - may be accepted and need not be declared. Of a value between £25 and £75 - may be accepted and must be declared using this form and countersigned by the line manager. Values of £75 or over - should be refused unless (in exceptional circumstances) approval is given by an Executive Director. A clear reason should be recorded on an organisation’s register(s) of interest as to why it was permissible to accept using this form

Name

Job Title


Declaration The following interests to declare (delete as appropriate)

Signed

Date

Email and extension number

Signed

Details of the gift* / hospitality* / sponsorship* offered * delete as appropriate



Name of organisation making the offer and relationship to the staff member and Trust (in case of an individual simply state whether a patient or relative)

Estimated value

Date offer made

In the case of hospitality / sponsorship date of event * delete as appropriate

Was prior approval or advice sought, if so, provide name, job title and date of person giving approval

Was offer accepted YES* / NO* (delete as appropriate)

Reason the offer was accepted or refused



Action taken if the offer was refused



REVIEW BY LINE MANAGER


Signed

Date

Name

Job Title



In the following cases approval is also required from an Executive Director:

• Gifts from an individual exceeding £50 in value • Sponsorship to attend an event overseas

REVIEW BY EXECUTIVE DIRECTOR


Signed Date Name Job Title


[email protected]


As per the Managing Conflicts of Interest in the NHS Guidance (June 2017) Organisations are required to publish the interests of decision making staff annually on the internet, in exceptional circumstances, an individual’s name and/or other information to be redacted from any

publicly available registers where the public disclosure of information could give rise to a real risk of harm or is prohibited by law.



APPENDIX 5 Equality Impact Assessment (EIA) Initial Screening Tool

Name of Policy or Service: Standards of Business Conduct and Conflicts of interest Policy

Name of Author:

Who is the policy or service aimed at? (Staff, Patients/Carers, Visitors/Public)

All Trust Staff

Description and aims of the policy/service

The aim of this policy is to help Trust staff and those who work with the Trust to understand what is expected of them in terms of standards of behaviour in conducting Trust business. The policy aims to ensure that the Trust is honest and impartial in the conduct of its business, Implementing the policy will help protect staff from any suspicion of corruption and protect the reputation of the Trust,

What outcomes are wanted from this policy/service?

To ensure that the Trust is honest and impartial in the conduct of its business and help protect staff from any suspicion of corruption and protect the reputation of the Trust.

Are there any factors that might prevent outcomes being achieved?

Noncompliance with policy

You must assess each of the 9 areas separately and consider: 1. Where you think that the policy/service could have a NEGATIVE impact on any of the equality

groups, i.e. it could disadvantage them 2. Where you think that the policy/service could have a POSITIVE impact on any of the equality

groups like promoting equality and equal opportunities or improving relations within equality groups

3. Where you think that this policy/service has a NEUTRAL effect on any of the equality groups listed below i.e. it has no effect currently on equality groups.

Equality Groups Positive impact

Negative impact

Neutral effect

If negative, please state why and the evidence used in your

assessment

Age? X

Sex (Male and Female)? X



Equality Groups Positive impact

Negative impact

Neutral effect

If negative, please state why and the evidence used in your

assessment

Disability (Learning Difficulties / Physical or Sensory disability)?

X

Race or Ethnicity? X

Religion, Faith or Belief? X

Sexual Orientation (gay, lesbian or heterosexual)?

X

Pregnancy and Maternity? X

Gender Reassignment (the process of transitioning from one gender to another)?

X

Marriage and Civil Partnership X

Mental Health X

Homelessness, Gypsy/Travellers, Refugees/Asylum seekers

X

If you have identified a negative impact to any of the above, you must complete a full Equality Impact Assessment Summary I declare that I have paid due regard to equality (i.e. promote equality of opportunity between communities/staff, eliminate discrimination that is unlawful, promote positive attitudes towards communities/staff) for this policy / service. I declare that in assessing the proposed policy / service I have identified that there is unlikely to be an adverse impact on different minority groups;

Name: Jonathan Ware Date: 9 July 2020 Post: Head of Financial Services Contact Number: 01895 279525



APPENDIX 6 Checklist for the review and ratification of Trust Policy Documents Policy Title: Standards of Business Conduct and Conflict of Interest Policy

Title of document being reviewed: Yes/No/ Unsure

Comments

1. Title

Is the title clear and unambiguous? Yes

Is it clear whether the document is a guideline, policy, protocol or standard? Yes

2. Rationale

Are reasons for development of the document stated? Yes

3. Development Process

Is the method described in brief? Yes

Are individuals involved in the development identified? Yes

Do you feel a reasonable attempt has been made to ensure relevant expertise has been used?

Yes

Is there evidence of consultation with stakeholders and users? Yes

4. Content

Is the objective of the document clear? Yes

Is the target population clear and unambiguous? Yes

Are the intended outcomes described? Yes

Are the statements clear and unambiguous? Yes

5. Evidence Base

Is the type of evidence to support the document identified explicitly? Yes

Are key references cited? Yes

Are the references cited in full? Yes

Are local/organisational supporting documents referenced? Yes

6. Approval

Does the document identify which committee/group will approve it? Yes



Title of document being reviewed: Yes/No/ Unsure

Comments

If appropriate, have the joint Human Resources/staff side committee (or equivalent) approved the document?

N/A

7. Dissemination and Implementation

Has the consultation record been completed? Yes

Is there an implementation action plan identifying how this will be done? Yes

Does the plan include the necessary training/support to ensure compliance? Yes

8. Document Control

Does the document identify where it will be held? Yes

Have archiving arrangements for superseded documents been addressed? Yes

9. Process for Monitoring Compliance

Are there measurable standards or KPI’s to support monitoring compliance of the document? Yes

Is there a plan to review or audit compliance with the document? Yes

10. Review Date

Is the review date identified? Yes

Is the frequency of review identified? If so, is it acceptable? Yes

11. Overall Responsibility for the Document

Is it clear who will be responsible for coordinating the dissemination, implementation and review of the documentation?

Yes



Minor Amendments Ratification Chair Approval

If as ratification committee/group chair you are happy to acknowledge and approve this document, please confirm this by email to the document author. Please enter your name and date of your approval in the box below. NB: A copy of the confirmation email must be sent to the Information Governance Team as evidence of approval before the document can be placed on to the intranet

Name Audit and Risk Committee Date

Ratification Committee/Group Approval

If the committee is happy to approve this document, please sign and date it and forward copies to the document author with responsibility for disseminating and implementing the document and the Governance Information Team who are responsible for maintaining the organisation’s database of approved documents. A copy of the minutes demonstrating ratification has been agreed must also be sent as evidence of completing the process.

Name Audit and Risk Committee Date
