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Whistle Blowing Policy and Procedure. Eve Scott, Jane Finnigan and Barry Lane Prepared by: Responsible Area: Approval Information:

Corporate Services Date Approved: COMMITTEE:-

Date Trust Board

Approved By:

Sign Print Name

Version No. Approved:


Review Date:

March 2008

Helena Corder

Reference to Standards for Better Health Domain

Third domain: Governance

Core/Development standard

Core Standard C8

Performance indicators

1. No instances of inappropriate disclosure 2 No incidents that could have been prevented by appropriate Disclosure

History of Document

CONTENTS Page 1. 2. 3. 4. 5. 6. 7. 8. 9

10 11. 12.

Introduction Policy Statement Associated Policies and Procedures Aims & Objectives Scope of this Policy. Examples of issues to disclose Staff rights and duties Responsibilities of the chief executive, directors, and Senior managers Procedure for raising concerns (Whistleblowing). 9.1 Informal Approach 9.2 Formal Approach 9.2.1 Stage 1 9.2.2 Stage 2 9.2.3 Final Stage General Points. Raising issues or concerns outside of the PCT Further Advice And Assistance

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3 3 4 4 4 4 5 5 6 6 6 6 7 7 7 8 8




The Public Interest Disclosure Act 1998 protects staff against unfair dismissal or victimisation in cases of an honest or legitimate disclosure. The usual limits on awards in employment tribunals will not apply under The Public Interest Disclosure Act. Staff unfairly dismissed for whistleblowing will be fully compensated for their losses. Awards for victimization which don’t result in dismissal will also be unlimited based on what is just and equitable in all the circumstances.


Under the Sex Discrimination Act 1975, Sex Discrimination Act (Amendments) Regulations 2003, Race Discrimination Act 1976 and Disability Discrimination Act 1995, Disability Discrimination Act (Amendments) Regulations 2003 Race Discrimination Act (Amendments) Regulations 2003 staff are protected if they suffer any detrimental treatment because they have made an allegation about mistreatment under the legislation.


Kirklees PCT is working to foster an open and transparent culture where staff can raise concerns without fear of recrimination. This policy sets out a process for raising concerns. The intension is that staff will feel sufficiently comfortable with the organisational culture that all concerns will be raised using the informal approach set out in Section 8.1. However, should the individual raising the concern not be satisfied with the management response, Section 8.2 sets out the formal approach. This section lays down the actions that must be taken by the manager to whom the concern is raised to respond to the concerns raised. This policy will be reviewed within twelve months in consultation with all PCT staff.


This policy should be read in conjunction with the Grievance policy and the Bullying and Harassment Policy, because it may be that it is more appropriate to use these frameworks to address the particular issue of concern.


Staff are also covered by the Employment Rights Act 1996 and the Health and Safety at Work Act 1974 if they disclose risks or concerns which they believe could harm people under the health and safety regulations.


There is a clause within PCT Contracts of Employment which takes account of the requirement within the Public Interest Disclosure Act to balance any disclosure of concerns against the need to protect patient and staff confidentiality. The contract states: 

This contractual relationship is founded on trust and any breach of this trust by you, relating to matters such as confidential records/documents, patients’ diagnoses or treatment, including any unauthorised communication of such information to a third party, will render you to disciplinary action and may result in dismissal. Should you, at any stage of your employment with us to raise any issues or concerns about the NHS, then details of how to do this can be found in the Trust’s Policy on Whistleblowing which is available from your manager or the Human Resources Department.


Policy Statement


Kirklees PCT is committed to encouraging a culture of openness where staff can express their ideas and concerns and these will be welcomed by the Chief Executive, Directors and Senior Managers as a contribution towards improving services

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within the PCT. The Chief Executive briefing session is intended to be a two way communication exercise. 2.2

In order to achieve the above, staff must feel able to offer their ideas for improving services and be confident enough to raise any matters of concern they may have.


This policy therefore takes account of The Public Interest Disclosure Act 1998 and HSC 1999/198 “Whistleblowing in the N.H.S.”


Individual staff grievances concerning their terms and conditions of employment should be raised through the PCT’s existing grievance procedure.


Associated Policies and Procedures  Business Code of Conduct and Commercial Sponsorship  Incident Reporting Policy  Discipline Policy  Grievance Policy  Bullying and Harrassment Policy  Confidentiality Policy


Aims & Objectives This policy and procedure exists to ensure that staff concerns can be addressed and dealt with without reference to any bodies outside the PCT. The broad aim of the Public Interest Disclosure Act is to encourage staff to disclose information through appropriate internal channels first rather than going directly to an outside body. As such, the Act makes it more difficult for staff to disclose information to the press and gain protection without first following the above procedures. The objectives are: 4.1

To advise all staff about their rights and duties including the legal position.


To assure staff that where honest and legitimate issues or concerns about the service are raised they will be protected and supported in doing so.


To advise about the type of issues or concerns which staff have a duty to disclose.


To advise staff about the correct way of raising issues or concerns.


To advise staff regarding the maintenance of confidential information


Scope of this Policy.


This policy must be followed by all directly employed PCT staff. It is offered as an example of best practice to independent N.H.S. contractors (doctors, dentists, ophthalmologists and pharmacists), and agency staff.


Examples of issues to disclose The following list provides examples of issues covered by this policy but the list is not

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intended to be exhaustive. 6.1 Negligent behaviour including misconduct and serious acts or omissions which threaten the well being of patients, the public, staff, or visitors, including any breach of the codes of conduct applying to the various professional groups in the N.H.S. 6.2 Theft of property from the PCT, patients, staff or visitors. 6.3 Any attempt to defraud the PCT, its officers, patients or visitors. 6.4 Wilful damage to the property of the PCT, patients, staff or visitors. 6.5 Corruption including the unlawful acceptance of money or goods in respect of services rendered. Further details of this can be found in the PCT’s Standards of Business Conduct and Commercial Sponsorship Policy. 6.6 Risks to staff, patients or visitor’s Health and Safety. 6.7 Failure by the PCT to meet its legal obligations. 6.8 Any criminal charges or offences which impact on a member of staff’s suitability to undertake his/her duties and which occurred at work or outside of work. 6.9 Damage to the environment either currently, in the past or likely in the future. 6.10 Issues pertinent to Child Protection or Vulnerable Adults Protection. 7.

Staff rights and duties 7.1

Individual members of staff have a right and duty to raise matters of concern regarding any aspect of health care services provided by and / or which impact on the PCT. This policy sets out the framework within which such disclosures should be made.


Staff are covered by The Public Interest Disclosure Act 1998 where they disclose information in good faith, following this policy, even if their suspicions turn out to be groundless. The PCT is committed to protecting staff who raise concerns in accordance with the terms of this policy. Such disclosures should be made to appropriate members of staff within the PCT. There is an expectation that disclosure outside the PCT will only occur as a last resort and with support and advice from a Trades Union Representative.


Staff must however balance their rights and duties to disclose issues, with their obligation to safeguard all confidential information, to which they have access, particularly information about patients.


In cases where staff are unclear about their obligations they may seek advice from the Human Resources Department or their Director before making a decision to disclose information outside the PCT. Alternatively staff may discuss the issue of concern with their supervisor or mentor, or they may at any stage seek advice from a representative of a trade union, professional association of a statutory body such as the Nursing and Midwifery Council (NMC) or General Medical Council (GMC).


Staff may be subject to disciplinary action following investigation and consideration in the following circumstances  making malicious and false allegations.  Failure to follow due process contained within this policy and procedure.


Staff should be aware of the timescales contained within this policy and act in accordance with them.

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Responsibilities of the chief executive, directors, and Senior managers 8.1

The Chief Executive has the ultimate responsibility to ensure that all staff can express their views or concerns and these are considered and dealt with thoroughly and fairly. The Chief Executive will be supported in this by their Directors and Senior Managers.


Management staff will always :  take concerns seriously;  consider them fully and sympathetically;  recognise that raising a concern can be difficult for some staff;  seek advice from other health care professionals where appropriate  treat concerns and issues raised in a confidential manner  Act in accordance with the deadlines contained within this policy and procedure.

PROCEDURE FOR RAISING CONCERNS (WHISLTLEBLOWING). 9.1 INFORMAL APPROACH 9.1.1 The aim should always be for staff concerns to be resolved informally between the individual and his or her line manager. In cases where the issue involves a person not employed by the PCT then the member of staff should approach their manager in the first instance for advice. If they are uncomfortable with approaching their manager or another PCT officer eg a member of the Human Resource Directorate, there is a confidential helpline run by an independent charity (Public Concern at Work) who will be able to provide advice. Their contact number is 020 7404 6609. 9.1.2 Where a staff concern can be acted upon, action should be taken promptly by the appropriate manager and the member of staff notified quickly of the action taken. 9.1.3 Where action is not considered practicable, appropriate, or in cases where staff concerns are groundless, the member of staff should be given a prompt and thorough explanation of the reasons for this. If the concern cannot, at the present time, be discussed or disclosed into the public domain, then the member of staff will be advised by their manager concerning the reason for this. 9.1.4 Staff would only be protected under the Public Interest Disclosure Act if the response given is unreasonable in the circumstances or in the opinion of the member of staff unsatisfactory. Staff should also be advised about the formal procedure stages, which are available under this policy. 9.1.5 The informal procedure should be completed within 5 working days of receipt of the concern. If it is not possible to meet the 5 day deadline eg because of the need for an investigation, the member of staff raising the concern should be informed of the reason and given an expected date when a response can be given. A deadline should not be extended beyond that needed to provide an efficient and effective response to the issue. 9.2


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9.2.1 STAGE 1 If a member of staff feels that the issue has not been addressed by the informal approach, then they should refer their concern to their Director. The Director may consult relevant parties and arrange a meeting with the member of staff within 5 working days of receipt of the concern (this may be extended by mutual agreement). The member of staff will be allowed to further clarify and explain their concern and the Director will give a response within 5 working days of the meeting. If the member of staff fails to invoke the next stage after the 5 days, it will be assumed they are satisfied with the outcome and do not wish to proceed to the next stage.

9.2.2 STAGE 2 If the member of staff is not satisfied with the Director’s response they may raise their concern with the Chief Executive. The Chief Executive may consult relevant parties and arrange to see the member of staff within 5 working days of receipt of the concern (this may be extended by mutual agreement). The member of staff will again be allowed the opportunity to clarify and explain why they remain dissatisfied with the decisions reached to date. The Chief Executive will give a response within 5 working days of the meeting. If the member of staff fails to invoke the next stage after the 5 days, it will be assumed they are satisfied with the outcome and do not wish to proceed to the next stage.

9.2.3 FINAL STAGE If the member of staff remains dissatisfied with the outcome, or when they initially raise their concern the member of staff does not feel (for whatever reason) that they can raise their concern through the normal procedure outlined above they may instead refer the matter to the Non-Executive Director who has been designated to hear issues or concerns under this procedure. The Non-Executive Director will meet with the member of staff within 10 working days of receipt of the concern and give a response within 10 working days of the meeting.


General Points.


At any stage of the procedure staff may present their issue either verbally or in writing. If an issue is raised verbally, a formal record will be made of the conversation.


Throughout the informal and formal stages of the procedure stages staff may request the assistance of their trade union or professional association representative or another person not acting in a legal capacity and they may be accompanied at any meeting arranged to consider their concern.


At the conclusion of the informal stage of the procedure and at the conclusion of each stage of the formal procedure, the member of staff will be advised that the timescale is 5 working days for invoking the next stage of the procedure. If the

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member of staff fails to invoke the next stage after the 5 days, it will be assumed they are satisfied with the outcome and do not wish to proceed to the next stage. All management decisions made during the formal stages will be confirmed in writing. 10.4

Should staff (for whatever reason) not wish to give their name, their concern will be addressed as far as possible. Staff should appreciate in this situation that it will be more difficult for management to look into the matter, protect the person’s position or give feedback.


Whilst the timetables referred to are a requirement, it is recognised that there may be occasions, whether due to holiday, sickness or other unavoidable circumstance, when they cannot be adhered to. In such exceptional cases, notice in writing must be given immediately to the relevant member of staff explaining the position and giving an indication of when the matter will be dealt with.

10.6 In order to expedite matters in the absence of a Director, the Chief Executive may designate another Director to act. Likewise, the Non-Executive Director has a nominated deputy to undertake the role in their absence. 11.



A member of staff who has exhausted the formal procedure but continues to be concerned about the decisions reached, can make a “protected” disclosure under the terms of the Public Information Disclosure Act to the following.  a legal adviser (made in the course of obtaining legal advice);  his/her Member of Parliament;  a Minister of the Crown;  a prescribed person (for example a statutory Health and Safety representative).


Disclosure of concerns to the media should be seen as a last resort when all other options have been exhausted. Staff are advised that they should seek advice from their trade union, professional association or legal representative before approaching the media. Staff may face disciplinary actions for any unjustifiable disclosure that might undermine public confidence in the health service. For example where the member discloses an unbalanced picture or is vindictive in their disclosures they would not be protected by the above legislation.


The PCT’s Counter Fraud Officer on number 01924 816098 if the concern is about fraud or corruption.


Advice can also be obtained from the PCT’s Director Corporate Services at St. Luke’s House. This Director has lead responsibility for this policy.


The independent charity Public Concern at Work, on 020 7404 6609.

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