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Conflicts of interest policy

Contents

  1. Policy summary
  2. Introduction
  3. Purpose
  4. Scope
  5. Responsibilities
  6. Procedure or implementation
  7. Training implications
  8. Monitoring arrangements
  9. Equality impact assessment screening
  10. Links to any other associated documents
  11. References

1 Policy summary

As a member of staff you should:

  • familiarise yourself with this policy and follow it. Refer to the guidance for the rationale behind this policy
  • use your common sense and judgement to consider whether the interests you have could affect the way taxpayers’ money is spent
  • regularly consider what interests you have and declare these as they arise. If in doubt, declare
  • not misuse your position to further your own interests or those close to you
  • not be influenced, or give the impression that you have been influenced by outside interests
  • not allow outside interests you have to inappropriately affect the decisions you make when using taxpayers’ money

As a trust we will:

  • ensure that this policy and supporting processes are clear and help staff understand what they need to do.
  • identify a team or individual(which is the director of corporate assurance) with responsibility for:
    • keeping this policy under review to ensure the policy is in line with the guidance
    • providing advice, training and support for staff on how interests should be managed
    • maintaining register(s) of interests
    • auditing this policy and its associated processes and procedures at least once every three years
  • not avoid managing conflicts of interest
  • not interpret this policy in a way which stifles collaboration and innovation with our partners

2 Introduction

Rotherham, Doncaster and South Humber NHS Trust (the ‘trust’), and the people who work with and for us, collaborate closely with other organisations, delivering high quality care for our patients.

These partnerships have many benefits and should help ensure that public money is spent efficiently and wisely. But there is a risk that conflicts of interest may arise.

Providing best value for taxpayers and ensuring that decisions are taken transparently and clearly, are both key principles in the NHS Constitution. We are committed to maximising our resources for the benefit of the whole community. As a trust and as individuals, we have a duty to ensure that all our dealings are conducted to the highest standards of integrity and that NHS monies are used wisely so that we are using our finite resources in the best interests of patients.

3 Purpose

This policy will help our staff manage conflicts of interest risks effectively. It:

  • introduces consistent principles and rules
  • provides simple advice about what to do in common situations
  • supports good judgement about how to approach and manage interests

This policy should be considered alongside these other trust policies:

3.1 Key terms

A ‘conflict of interest’ 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.

A conflict of interest may be:

  • actually, 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

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.

The Bribery Act (2010) introduced a number of offences:

  • offering, promising, or giving a bribe to another person to perform a relevant ‘function or activity’ improperly, or to reward a person for the improper performance of such a function or activity
  • requesting, agreeing to receive, or accepting a bribe to perform a function or activity improperly irrespective of whether the recipient of the bribe requests or receives it directly or through a third party, and irrespective of whether it is for the recipient’s benefit

A new corporate offence was also introduced:

  • failure of a commercial organisation to prevent bribery

This means that the trust can be held responsible if it fails to enact adequate procedures to prevent bribery.

3.2 Interests

Interests fall into the following categories:

  • financial interests, where an individual may get direct financial benefit (this may be a financial gain, or avoidance of a loss) 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
  • indirect interests, where an individual has a close association (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.) with another individual who has a financial interest, a non-financial professional interest or a nonfinancial personal interest and could stand to benefit from a decision they are involved in making

3.3 Staff

At the trust we use the skills of many different people, all of whom are vital to our work. This includes people on differing employment terms and for the purposes of this policy references to ‘staff’ will include:

  • all salaried employees
  • all prospective employees who are part-way through recruitment
  • contractors and sub-contractors
  • agency staff
  • committee, sub-committee and advisory group members (who may not be directly employed or engaged by the trust)
  • volunteers

3.4 Decision making staff

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. For the purposes of this guidance these people are referred to as ‘decision making staff.’

The decision making staff in this trust are:

  • executive and non-executive directors (or equivalent roles)
  • care group triumvirates
  • all staff on agenda for change band 8b and above
  • medical consultants
  • medical prescribers
  • non-Medical prescribers
  • purchasing department staff
  • estates senior managers

The list of decision making staff is agreed periodically by the Executive Management team and held by the director of corporate assurance.

4 Scope

The general principles of the policy are that all staff working for the trust under NHS terms and conditions are covered by the policy.

All employees have a responsibility for ensuring that they are not placed in a position, which risks or appears to risk, a conflict between their private interests and their NHS duties.

Continuous maintenance of the individuals’ declarations of interests is the responsibility of the individual. The individual must keep the trust up to date with any declarations.

5 Responsibilities

The director of corporate assurance is responsible for:

  • ensuring that the guidelines within the conflict of interests policy are brought to the attention of all employees
  • ensuring that the procedures are put in place for ensuring that they are effectively implemented and monitored
  • the upkeep of the conflict of interest register
  • for compiling an annual report for presentation to the audit committee

Line managers are responsible for ensuring all staff are aware of the policy.

It is the responsibility of all trust staff to ensure that they are not placed in a position which risks, or may risk, conflict between their private interests and their NHS duties.

It is the responsibility of all trust staff to declare information to be held on the conflict of interests register. Failure to do so may result in disciplinary procedures against individual members of staff.

6 Procedure or implementation

6.1 Identification, declaration and review of interests

6.1.1 Identification and declaration of interests (including gifts and hospitality)

All staff should identify and declare material interests at the earliest opportunity (and in any event within 28 days (for example within 28 days of receiving a gift)). If staff are in any doubt as to whether an interest is material then they should declare it, so that it can be considered. Declarations should be made:

  • on appointment with the trust
  • when staff move to a new role or their responsibilities change significantly
  • at the beginning of a new project or 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)

Declarations should be made to the director of corporate assurance, who will also provide advice on issues relating to the implementation of this policy. The minimum information required is:

  • name and their role with the trust
  • a description of the interest declared
  • relevant dates relating to the interest

Further information will be required depending upon the type of declaration being made.

After expiry, an 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.

6.1.2 Proactive review of interests

Decision making staff will be prompted annually (by the Corporate Assurance team) to review declarations they have made and, as appropriate, update them or make a nil return.

6.2 Records and publication

6.2.1 Maintenance

The trust will maintain a register for each type of declaration set out in section 11.

6.2.2 Publication

We will:

  • publish the interests declared by decision making staff on the trust’s website and refresh this information as updates and new declarations are made

If decision making staff have substantial grounds for believing that publication of their interests should not take place then they should contact the director of corporate assurance to explain why.  In exceptional circumstances, for instance where publication of information might put a member of staff at risk of harm, 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.

6.2.3 Wider transparency initiatives

The trust fully supports wider transparency initiatives in healthcare, and we encourage staff to engage actively with these.

Relevant staff are strongly encouraged to give their consent for payments they receive from the pharmaceutical industry to be disclosed as part of the association of British pharmaceutical industry (ABPI) disclosure UK initiative. These “transfers of value” include payments relating to:

  • speaking at and chairing meetings
  • training services
  • advisory board meetings
  • fees and expenses paid to healthcare professionals
  • sponsorship of attendance at meetings, which includes registration fees and the costs of accommodation and travel, both inside and outside the UK
  • donations, grants and benefits in kind provided to healthcare organisations

Further information about the scheme can be found on the association of the British pharmaceutical industry website (opens in new window).

6.3 Management of interests, general

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 the management actions that could be applied 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

Each case will be different and context-specific, and the trust will always clarify the circumstances and issues with the individuals involved. Line managers should maintain a written audit trail of information considered and actions taken and of any consultations with HR and director of corporate assurance so as to ensure consistency of response.

Staff who declare material interests should make their line manager or the person(s) they are working to aware of their existence.

6.4 Management of interests, common situations

This section sets out the principles and rules to be adopted by staff in common situations, and what information should be declared.

6.4.1 Gifts

Staff should not accept gifts that may affect, or be seen to affect, their professional judgement.

Gifts from suppliers or contractors:

  • gifts from suppliers or contractors doing business (or likely to do business) with the trust should be declined, whatever their value
  • low cost branded promotional aids such as pens or post-it notes may, however, be accepted where they are under the value of £6 (The £6 value has been selected with reference to existing industry guidance issued by the ABPI ) in total, and need not be declared

Gifts from other sources (for example, patients, families, service users):

  • gifts of cash and vouchers to individuals should always be declined
  • staff should not ask for any gifts
  • gifts valued at over £50 should be treated with caution and only be accepted on behalf of the trust and not in a personal capacity. These should be declared by staff
  • modest gifts accepted under a value of £50 do not need to be declared
  • a common sense approach should be applied to the valuing of gifts (using an actual amount, if known, or an estimate that a reasonable person would make as to its value)
  • multiple gifts from the same source over a 12 month period should be treated in the same way as single gifts over £50 where the cumulative value exceeds £50

What should be declared:

  • staff name and their role with the trust
  • a description of the nature and value of the gift, including its source
  • date of receipt
  • any other relevant information (for example, circumstances surrounding the gift, action taken to mitigate against a conflict, details of any approvals given to depart from the terms of this policy)

6.4.2 Hospitality

  • 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
  • particular caution should be exercised when hospitality is offered by actual or potential suppliers or contractors. This can be accepted, and must be declared, if modest and reasonable.  Senior approval must be obtained

Meals and refreshments:

  • under a value of £25 may be accepted and need not be declared
  • of a value between £25 and £75 (the £75 value has been selected with reference to existing industry guidance issued by the ABPI) may be accepted and must be declared
  • over a value of £75  should be refused unless (in exceptional circumstances) approval from the care group director or a member of the Executive Management team (EMT) is given. A clear reason should be recorded on the trust’s register(s) of interest as to why it was permissible to accept
  • a common sense approach should be applied to the valuing of meals and refreshments (using an actual amount, if known, or a reasonable estimate)

Travel and accommodation:

  • 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
  • offers which go beyond modest, or are of a type that the trust itself might not usually offer, need approval from the care group director or a member of the Executive Management team (EMT), and should only be accepted in exceptional circumstances, and must be declared. A clear reason should be recorded on the trust’s register(s) of interest as to why it was permissible to accept travel and accommodation of this type

A non-exhaustive list of examples includes:

  • offers of business class or first class travel and accommodation (including domestic travel)
  • offers of foreign travel and accommodation

What should be declared:

  • staff name and their role with the trust
  • the nature and value of the hospitality including the circumstances
  • date of receipt
  • any other relevant information (for example, action taken to mitigate against a conflict, details of any approvals given to depart from the terms of this policy)

6.4.3 Outside employment

  • staff should declare any existing outside employment on appointment and any new outside employment when it arises
  • where a risk of conflict of interest arises, the general management actions outlined in this policy should be considered and applied to mitigate risks
  • where contracts of employment or terms and conditions of engagement permit, staff may be required to seek prior approval from the trust to engage in outside employment

The trust may also have legitimate reasons within employment law for knowing about outside employment of staff, even when this does not give rise to risk of a conflict for example to ensure the requirements of working time regulations are adhered to.  

What should be declared:

  • staff name and their role with the trust
  • the nature of the outside employment (for example, who it is with, a description of duties, time commitment)
  • relevant dates
  • other relevant information (for example, action taken to mitigate against a conflict, details of any approvals given to depart from the terms of this policy)

6.4.4 Shareholdings and other ownership issues

  • Staff should declare, as a minimum, any shareholdings and other ownership interests in any publicly listed, private or not-for-profit company, business, partnership or consultancy which is doing, or might be reasonably expected to do, business with the trust.
  • Where shareholdings or other ownership interests are declared and give rise to risk of conflicts of interest then the general management actions outlined in this policy should be considered and applied to mitigate risks.
  • There is no need to declare shares or securities held in collective investment or pension funds or units of authorised unit trusts or in such as large commercial utility firms, banks or large retailers.

What should be declared:

  • staff name and their role with the trust
  • nature of the shareholdings or other ownership interest
  • relevant dates
  • other relevant information (for example, action taken to mitigate against a conflict, details of any approvals given to depart from the terms of this policy)

6.4.5 Patents

  • Staff should declare 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 trust’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 policy should be considered and applied to mitigate risks.

What should be declared:

  • staff name and their role with the trust
  • a description of the patent
  • relevant dates
  • other relevant information (for example, action taken to mitigate against a conflict, details of any approvals given to depart from the terms of this policy)

6.4.6 Loyalty interests

Loyalty interests should be declared by staff involved in decision making where they:

  • hold a position of authority in another NHS Trust 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 an 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. (please refer to the relationships at work policy)
  • are aware that their trust does business with an organisation in which close family members and relatives, close friends and associates, and business partners have decision making responsibilities

What should be declared:

  • staff name and their role with the trust
  • nature of the loyalty interest
  • relevant dates
  • other relevant information (for example, action taken to mitigate against a conflict, details of any approvals given to depart from the terms of this policy)

6.4.7 Donations

  • Donations made by suppliers or bodies seeking to do business with the trust should be treated with caution and not routinely accepted. In exceptional circumstances they 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.
  • Staff should not actively solicit charitable donations unless this is a prescribed or expected part of their duties for the trust, or is being pursued on behalf of the trust’s own registered charity or other charitable body and is not for their own personal gain.
  • Staff must obtain permission from the trust (from the care group Director or a member of the Executive Management team (EMT) if in their professional role they intend to undertake fundraising activities on behalf of a pre-approved charitable campaign for a charity other than the trust’s own.
  • 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 the trust’s charitable fund in lieu of receiving a professional fee 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.

What should be declared:

  • the trust will maintain records in line with the above principles and rules and relevant obligations under charity law

6.4.8 Sponsored events

  • Sponsorship of events by appropriate external bodies will only be approved if a reasonable person would conclude that the event will result in clear benefit to the trust and the NHS.
  • 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 whom they could gain a commercial advantage, and information which is not in the public domain should not normally be supplied.
  • At the trust’s discretion, sponsors or their representatives may attend or take part in the event but they should not have a dominant influence over the content or the main purpose of the event.
  • The involvement of a sponsor in an event should always be clearly identified.
  • Staff within the trust involved in securing sponsorship of events should make it clear that sponsorship does not equate to endorsement of a company or its products and this should be made visibly clear on any promotional or other materials relating to the event.
  • Staff arranging sponsored events must declare this to the trust.

What should be declared:

  • the trust will maintain records regarding sponsored events in line with the above principles and rules

6.4.9 Sponsored research

  • Funding sources for research purposes must be transparent.
  • Any proposed research must go through the relevant health research authority or other approvals process.
  • There must be a written protocol and written contract between staff, the trust, and or institutes at which the study will take place and the sponsoring organisation, which specifies the nature of the services to be provided and the payment for those services.
  • The study must not constitute an inducement to prescribe, supply, administer, recommend, buy or sell any medicine, medical device, equipment or service.
  • Staff should declare involvement with sponsored research to the trust.

What should be declared:

  • the trust will retain written records of sponsorship of research, in line with the above principles and rules

Staff should declare:

  • their name and their role with the trust
  • nature of their involvement in the sponsored research
  • relevant dates
  • other relevant information (for example, what, if any, benefit the sponsor derives from the sponsorship, action taken to mitigate against a conflict, details of any approvals given to depart from the terms of this policy)

6.4.10 Sponsored posts

  • External sponsorship of a post requires prior approval from the trust.
  • Rolling sponsorship of posts should be avoided unless appropriate checkpoints are put in place to review and withdraw if appropriate.
  • Sponsorship of a post should only happen where there is written confirmation that the arrangements will have no effect on purchasing decisions or prescribing and dispensing habits. This should be audited for the duration of the sponsorship. Written agreements should detail the circumstances under which trusts have the ability to exit sponsorship arrangements if conflicts of interest which cannot be managed arise.
  • Sponsored post holders must not promote or favour the sponsor’s products, and information about alternative products and suppliers should be provided.
  • Sponsors should not have any undue influence over the duties of the post or have any preferential access to services, materials or intellectual property relating to or developed in connection with the sponsored posts.

What should be declared:

  • the trust will retain written records of sponsorship of posts, in line with the above principles and rules
  • staff should declare any other interests arising as a result of their association with the sponsor, in line with the content in the rest of this policy

6.4.11 Clinical private practice

Clinical staff should declare all private practice on appointment, and or any new private practice when it arises (Hospital consultants are already required to provide their employer with this information by virtue of paragraph 3 Sch. 9 of the Terms and Conditions Consultants (England) 2003 (opens in new window)).

Including:

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

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

  • seek prior approval of their trust before taking up private practice
  • ensure that, where there would otherwise be a conflict or potential conflict of interest, NHS commitments take precedence over private work (These provisions already apply to Hospital Consultants by virtue of Paras.5 and 20, Sch. 9 of the Terms and Conditions, Consultants (England) 2003))
  • not accept direct or indirect financial incentives from private providers other than those allowed by competition and markets authority guidelines
  • declare private professional services or fee paying services for other organisations, for example, consultancy work such as medical assessments for insurance companies

Hospital consultants should not initiate discussions about providing their private professional services for NHS patients, nor should they ask other staff to initiate such discussions on their behalf.

What should be declared:

  • staff name and their role with the trust
  • a description of the nature of the private practice (for example, what, where and when staff practise, sessional activity, etc)
  • relevant dates
  • any other relevant information (for example, action taken to mitigate against a conflict, details of any approvals given to depart from the terms of this policy)

6.5 Management of interests, advice in specific contexts

6.5.1 Strategic decision making groups

In common with other NHS bodies the trust uses a variety of different groups to make key strategic decisions about things such as:

  • entering into (or renewing) large scale contracts
  • awarding grants
  • making procurement decisions
  • selection of medicines, equipment, and devices

The interests of those who are involved in these groups should be well known so that they can be managed effectively. For this trust these groups are:

  • board of directors
  • finance, performance and informatics committee
  • estates sub committee
  • health informatics sub committee
  • quality committee
  • medicines management committee
  • charitable funds committee
  • research panel
  • council of governors

These groups should adopt the following principles:

  • chairs should consider any known interests of members in advance, and begin each meeting by asking for declaration of relevant material interests
  • members should take personal responsibility for declaring material interests at the beginning of each meeting and as they arise
  • any new interests identified should be added to the trust’s register(s)
  • the vice chair (or other non-conflicted member) should chair all or part of the meeting if the chair has an interest that may prejudice their judgement

If a member has an actual or potential interest the chair should consider the following approaches 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

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.

6.5.2 Procurement

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.

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.

6.6 Dealing with breaches

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’.

6.6.1 Identifying and reporting breaches

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 director of corporate assurance by email at rdash.doi@nhs.net or by telephone on 03000 213 000.

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.  For further information about how concerns should be raised please access the freedom to speak up policy.

The trust will investigate each reported breach according to its own specific facts and merits, and give relevant parties the opportunity to explain and clarify any relevant circumstances.

Following investigation the trust will:

  • decide if there has been or is potential for a breach and if so 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 trust should be made aware
  • take appropriate action as set out in the next section

6.6.2 Taking action in response to breaches

Action taken in response to breaches of this policy will be in accordance with the disciplinary procedures of the trust and could involve trust leads for staff support (for example, human resources), fraud (for example, local counter fraud specialists), members of the management or executive teams and trust auditors.

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 or employment law or contractual action should be taken in relation to staff or others
  • consideration being given to escalation to external parties. This might include referral of matters to external auditors, NHS counter fraud authority, the police, statutory health bodies (such as NHS England, NHS improvement or the care quality commission (CQC)), and or health professional regulatory bodies

Inappropriate or ineffective management of interests can have serious implications for the trust and staff. There will be occasions where it is necessary to consider the imposition of sanctions for breaches.

Sanctions should not be considered until the circumstances surrounding breaches have been properly investigated. However, if such investigations establish wrong-doing or fault then the trust 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 in relation to staff which might include:

  • informal action (such as signposting to training and or guidance)
  • formal disciplinary action (such as formal warning, the requirement for additional training, re-arrangement of duties, redeployment, or dismissal)
  • reporting incidents to the external parties described above (third bullet point in previous section) 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 that caused the breach
  • legal action, such as investigation and prosecution under fraud, bribery and corruption legislation

6.6.3 Learning and transparency concerning breaches

Reports on breaches, the impact of these, and action taken will be considered by the audit committee at least every six months.

To ensure that lessons are learnt and management of interests can continually improve, anonymised information on breaches, the impact of these, and action taken will be prepared and published as appropriate, or made available for inspection by the public upon request.

6.6.4 Working whilst absent due to sickness

Employees must not take up any paid or unpaid employment during periods of study leave. Such conduct may be treated as gross misconduct under the trust’s disciplinary procedure and a referral will be made to the trust’s local counter fraud specialist in line with the counter fraud, bribery and corruption policy.

6.6.5 Working whilst absent due to study leave

6.7 Review

This policy will be reviewed on a maximum 3 yearly basis unless an earlier review is required. This will be led by the director of corporate assurance.

7 Training implications

There are no specific training needs in relation to this policy, but as a trust policy, all staff need to be aware of the key points that the policy covers. Staff can be made aware through local induction, team meetings and communications daily emails.

NHS England has published a range of supporting guides (opens in new window).

8 Monitoring arrangements

8.1 Monitor compliance with the policy

  • How: Completion of an annual report.
  • Who: Board secretary.
  • Reported to: Audit committee.
  • Frequency: Annually.

8.2 Register updates

  • How: Production of the registers.
  • Who: Board secretary.
  • Reported to: Audit committee.
  • Frequency: Annually.

8.3 Review of the system

  • How: Audit.
  • Who: Internal audit.
  • Reported to: Audit committee.
  • Frequency: According to the annual risk assessment as part of the annual audit plan preparation, but at least once every three years.

9 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

9.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

9.1.1 How this will be met

No issues have been identified.

9.2 Mental Capacity Act 2005

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

9.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

11 References

12 Appendices

12.1. Declaration of interests form

Please see below for information on how to populate the above boxes. The information submitted will be held by Rotherham, Doncaster and South Humber NHS Foundation Trust (the trust) for personnel or other reasons specified on this form and to comply with the trust’s policies. This information may be held in both manual and electronic form in accordance with the Data Protection Act 2018 (including General Data Protection Regulations (GDPR) May 2018).  Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000 and published in registers that the trust holds. I confirm that the information provided above is complete and correct. I acknowledge that any changes in these declarations must be notified to the trust as soon as practicable and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, internal disciplinary or professional regulatory action may result. I do or do not (delete as applicable) give my consent for this information to published on registers that the trust holds. If consent is not given please give reasons, guidance notes for completion of specimen interests declaration form.

Declaration of interests form
Name Mr John Smith
Role Senior policy manager, commissioning directorate, organisation
Description of interest: Hospitality received £95 from Organisation Z to pay for travel to speak at conference on managing conflicts of interest on 21-12-16
From 21-12-2016
To 21-12-2016
Comments: Approval to attend event and accept hospitality given by Mary Baker, Head of Unit.
If there is nothing to declare, please state ‘nil declaration’.
Signed:
Date:
Please return this form to director of corporate assurance or board secretary, RDaSH, Woodfield House, Tickhill Road Site, Balby, Doncaster, South

Yorkshire, DN4 8QN or email rdash.doi@nhs.net
Name and role: Insert your name and your position or role in relation to the organisation you are making the return to
1) No interest to declare If there is nothing to declare, please state ‘nil declaration’.
2) Description of interest: Provide a description of the interest that is being declared. This should contain enough information to be meaningful (for example, detailing the supplier of any gifts, hospitality, sponsorship, etc.). That is, the information provided should enable a reasonable person with no prior knowledge should be able to read this and understand the nature of the interest

Types of interest:

  • financial interests, this is where an individual may get direct financial benefits from the consequences of a decision they are involved in making
  • mon-financial professional interests, this is 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 status or promoting their professional career
  • non-financial personal interests, this is 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
  • indirect interests, this is where an individual has a close association with another individual who has a financial interest, a non financial professional interest or a non-financial personal interest who would stand to benefit from a decision they are involved in making
  • a benefit may arise from both a gain or an avoidance of a loss

Declaration of interest form
Relevant dates: Detail here when the interest arose and, if relevant, when it ceased
Comments: This field should detail any action taken to manage an actual or potential conflict of interest. It might also detail any approvals or permissions to adopt a certain course of action

Document control

  • Version: 4.1.
  • Unique reference number: 254.
  • Date approved: 28 December 2023.
  • Approved by: Corporate policy approval group.
  • Name of originator or author: Risk officer.
  • Name of responsible individual: Director of  corporate assurance or board secretary.
  • Date issued: 8 January 2024.
  • Review date: June 2024.
  • Target audience: All staff, prospective employees, contractors, subcontractors, agency staff, volunteers, committee, sub-committee and advisory group members engaged by the trust.

Page last reviewed: April 30, 2024
Next review due: April 30, 2025

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