Code of Business Conduct for Trust Staff

Transcription

1 Code of Business Conduct for Trust Staff Version: Version 5.1 (January 2018) Adopted by: Version 5 adopted September 2017 Amendments approved January 2018 (v 5.1) Date adopted: (original) October/November 2011 Name of Frank Lusk, Trust Secretary originator/author Name of responsible committee: Date issued for publication: Finance and Performance Committee January 2018 Review date: September 2018 Expiry date: September 2019 Target audience: Type of Policy (tick appropriate box) State Relevant Fundamental CQC Standards All Staff Clinical Non Clinical Regulation 17 Good Governance

2 CONTENTS 1.0 INTRODUCTION BY THE CHIEF EXECUTIVE WHY WE HAVE A CODE 2.1 Three Fundamental Public Service Values 2.2 Bribery Act Aims of the Code 2.4 Summary Guide PROFESSIONAL CONDUCT BUSINESS CONDUCT 4.1 Expectations of staff 4.2 Responsibilities of Staff 4.3 Failure to follow/breaches of the Code 4.4 Monitoring the Code 5.0 CONFLICTS OF INTEREST - GENERAL Categories of interests 6.0 GIFTS AND HOSPITALITY 6.1 Gifts 6.2 Hospitality 6.3 Process for Notification of Gifts and Hospitality 7.0 SPONSORSHIP 7.1 Definition 7.2 Commercial Sponsorship Meetings 7.3 Commercial Sponsorship for Collaborative Partnerships 7.4 Commercial Sponsorship for Attendance at Courses and Conferences 7.5 Process for the Notification of Sponsorship 8.0 DECLARATIONS OF INTEREST 8.1 General 8.2 Declarations 8.3 Strategic decision making groups APPLICATION FOR EMPLOYMENT WITHIN THE TRUST OUTSIDE EMPLOYMENT/PRIVATE PRACTICE 10.1 General Principles 10.2 Medical Staff 11.0 MAINTAINING CONFIDENTIALITY 11.1 Standards Expected for Information Confidentiality 11.2 Guidance on Questions of Confidentiality 11.3 Failure to Maintain Confidentiality 11.4 Maintaining Information Security TENDERING AND CONTRACT PROCEDURES 22 LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 2 of 37

3 12.1 Staff Involvement 12.2 Fair and Open Competition in procurement 12.3 Preferential Treatment in Private Transactions 13.0 GUIDANCE ON FRAUD, BRIBERY AND CORRUPTION 13.1 Board Commitment 13.2 Acting on Suspected Fraud, Bribery and Corruption FREEDOM TO SPEAK UP GUARDIAN MONITORING COMPLIANCE AND EFFECTIVENESS 24 APPENDICES Appendix A - Potential risks ( Red Flags ) Appendix B - Flowchart for assisting decision on acceptance of gifts/ hospitality Appendix C - Registration Form - Notification of the Offer of Gifts, Hospitality & Sponsorship Appendix D - Local Hospitality Registers Appendix E - Process for Registering Offers of Gifts and Hospitality Appendix F - Declaration of Interests Flowchart Appendix G - Declaration of Interest Pro Forma Appendix H - Form for the Notification of the offer of sponsorship (for use by medical staff, and to accompany study leave form) Appendix I I1 Policy Training Requirements I2 NHS Constitution Checklist I3 Stakeholder and Consultation I4 Due Regard Screening Template Statement LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 3 of 37

4 Version Control and Summary of Changes Version Date number Refresh Version 2 May 2012 Refresh Version 3 Refresh Version 3.1 Refresh Version 3.2 Refresh Version 3.3 Refresh Version 3.4 Refresh.Version 3.5 Refresh.Version 3.6 Refresh..Version 3.7 April 2013 August 2013 October 2013 April 2014 November 2014 June 2015 July 2015 October 2015 Comments (description change and amendments) Reference to a designated Compliance Officer with specific responsibility for the Bribery Act in terms of reporting and monitoring, (included in Section 3.2, and in Appendix A Inclusion of Monitoring of the Code arrangements Inclusion of need to declare when receiving honorarium payments (in 8.2 Declarations, and in Appendix F) Strengthening of links to the Trust s Disciplinary Policy and Procedure Inclusion of Appendix of Potential risks ( Red Flags ) Inclusion of Appendix H copy of pro forma within HR induction paperwork containing statement confirming understanding of Code, for confirmation. Correction of minor type errors, Section 6.6.1, 6.6.3, Appendix D reference to Audit and Assurance Committee Change of Chief Executive s name, Introduction by the Chief Executive, page 6. Clarification of flowchart in Figure 1 (page 9) in relation to Commercial Sponsorship at meetings Annual review of list of Red Flag Risks; inclusion of 1.27 (page 27) Inclusion of reference to Second Opinion Advice process (section , page 45) Charitable Funds processes - clarification of required reporting of elements (Section on page 14) Inclusion of requirement for Nil Returns, and strengthening of requirement of knowledge of declined offers, in line with findings of Internal Audit review (pages 15 and 16) Declaration of interests unrelated to work (page 19) Changes to titles of Director of Finance, and Trust Secretary (throughout) Counter Fraud updates Removal of items that can change over time eg telephone numbers, questions asked in surveys Updated references eg e-communications policy reference and Local Register Holders list (Annex C). Removal of Appendix H Local Induction Checklist as changeable HR owned list of actions for new starters. Update of local register holders in Appendix C Removal of contact details (go out of date) from LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 4 of 37

5 Review. Version 4 Review. Version 5 Refresh. Version 5.1 January 2017 September 2017 January 2018 Review of layout to present clearer advice, reduce repetition and comply with Template for Developing Procedural Document. Inclusion of additional information to reflect NHS England s consultation on proposals to strengthen the management of conflicts of interest. Review against NHS England guidance on Managing Conflicts of Interest in the NHS effective from June 2017 To reflect recommendations from 360 Assurance audit 1718/LPT/09 November 2017 All LPT Policies can be provided in large print or Braille formats, if requested, and an interpreting service is available to individuals of different nationalities who require them. Did you print this document yourself? Please be advised that the Trust discourages the retention of hard copies of policies and can only guarantee that the policy on the Trust website is the most up-to-date version. For further information contact: Trust Secretary Equality Statement Leicestershire Partnership NHS Trust (LPT) aims to design and implement policy documents that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account the provisions of the Equality Act 2010 and advances equal opportunities for all. This document has been assessed to ensure that no one receives less favourable treatment on the protected characteristics of their age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender) or sexual orientation. In carrying out its functions, LPT must have due regard to the different needs of different protected equality groups in their area. This applies to all the activities for which LPT is responsible, including policy development, review and implementation. Due Regard LPT must have due regard to the aims of eliminating discrimination and promoting equality when policies are being developed. Information about due regard can be found on the Equality page on e-source and/or by contacting the LPT Equalities Team. The Due regard assessment template is Appendix H4 of this document LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 5 of 37

6 1.0 INTRODUCTION BY THE CHIEF EXECUTIVE The Chief Executive of the NHS has designated me the Accountable Officer for the Trust in my capacity as Trust Chief Executive. As Accountable Officer, I have overall responsibility for ensuring that the Trust operates efficiently, economically and with probity. Probity is one of the crucial public service values which underpins the work not only of this Trust but of the NHS as a whole. The NHS, like all organisations which receive public funds, is required to demonstrate a high standard of conduct in the way it carries out its work. The purpose of the Code of Business Conduct for Trust Staff (referred to as the Code ) is to outline the principles to be followed by each member of staff to ensure that this is the case. The Trust requires of its staff high standards of corporate and personal conduct, based on the recognition that patients come first. The Code is intended to:- make all staff aware of the Trust s expectations of their conduct and behaviour; give staff the knowledge and information they need to protect themselves from situations that may draw criticism or even disciplinary action; enable members of staff to express their concerns in an open and unthreatening way; demonstrate the high standards of business conduct which the Trust Board has adopted as guiding principles for the conduct of all Trust activities. All staff will need to be fully committed to the Code, and to make it part of their everyday working ethos. This document should be read in conjunction with; the NHS Code of Conduct and Accountability 2004, the regulations and guidelines set out in the Standing Orders and Standing Financial Instructions of Leicestershire Partnership NHS Trust, and the Professional Codes as followed by professional staff groups. The document, Good Psychiatric Practice: Relationships with pharmaceutical and other commercial organisations (Royal College of Psychiatrists) should also be reviewed by those dealing with such bodies. If you would like to discuss any aspects of the Code please contact the Trust Secretary who will be pleased to help. Peter Miller Chief Executive LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 6 of 37

7 2.0 WHY WE HAVE A CODE 2.1 Three Fundamental Public Service Values There are three fundamental public service values (Code of Conduct and Accountability for NHS Boards: Department of Health, 2004) which underpin the work of the NHS:- Accountability - everything done by staff who work in the Trust must be able to stand the test of Parliamentary scrutiny, public judgements on propriety and professional codes of conduct. Probity - there must be an absolute standard of honesty in dealing with the assets of the Trust: integrity should be the hallmark of all personal conduct in decisions affecting patients, colleagues and suppliers, and in the use of information acquired in the course of discharging Trust duties. Openness - there must be sufficient transparency about the business of the Trust to promote confidence between the Trust and its staff, patients and the public. In addition, staff are expected to uphold the seven principles of public life known as the Nolan Principles : Selflessness, Integrity, Objectivity, Accountability, Openness, Honesty, and Leadership. 2.2 Bribery Act 2010 Bribery is the offering of an incentive to someone to do something which they would not normally do. The Bribery Act 2010 introduced four criminal offences, which are, in broad terms:- Bribing someone Being bribed (ie receiving a bribe) Bribing a foreign public official, and (for a commercial organisation) failure to prevent bribery The Act reforms the criminal law of bribery, making it easier to tackle this offence proactively in the public and private sectors. It introduces a corporate offence which means that relevant commercial organisations will be exposed to criminal liability for failing to prevent bribery. Appendix A gives a list of possible circumstances which may raise concerns under various anti-bribery and anti-corruption laws. The list is not intended to be exhaustive and is for illustrative purposes only. All employees of LPT must ensure that they adhere to the highest of standards. For further information please contact the Trust s designated Compliance Officer (Trust Secretary), or contact Counter Fraud Specialist. 2.3 Aims of the Code The Code is intended to lay down guidelines which will help staff maintain the values of accountability, probity, and openness. It aims to:- LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 7 of 37

8 make staff aware of the Trust s expectations of their business conduct and behaviour; demonstrate the high standards of business conduct which the Trust Board has adopted as guiding principles for the conduct of all Trust activities; set out the procedure should gifts, hospitality and sponsorship of a commercial or non-commercial nature be offered to any member of Trust staff; help to ensure that we use NHS money wisely, providing best value for taxpayers and accountability to our patients for the decisions we take. The Code is underpinned by the Trust s Disciplinary Policy and Procedure. It also reflects the spirit of the NHS England Guidance Managing Conflicts of Interest in the NHS issued in The Code sets out the definitions and descriptions, setting parameters for the acceptance of gifts to ensure compliance with the Code, and the principles of sound corporate governance. For clarification, the term staff in the Code includes; 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 organisation). 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 the Code these people are referred to as decision making staff. Decision making staff in this organisation are: Executive and Non-Executive Directors Members of advisory groups which contribute to direct or delegated decision making on the provision of taxpayer funded services Those at Agenda for Change band 8d and above Administrative and clinical staff who have the power to enter into contracts on behalf of the Trust Administrative and clinical staff involved in decision making concerning the commissioning of services, purchasing of goods, medicines, medical devices or equipment, and formulary decisions. 2.4 Summary guide OVERVIEW:- all staff must abide by this Code and consult their line manager if they are unsure; staff must make sure they are not in a position where their private interests and NHS duties may conflict; staff should conduct themselves openly and transparently, with integrity, impartiality and honesty; it is the responsibility of all staff to raise concerns regarding staff business conduct; generally, gifts, hospitality and sponsorship should not be accepted, but where, by exception, an individual believes there is a case for acceptance, appropriate approval must be obtained; LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 8 of 37

9 any relevant interests must be declared; decisions involving expenditure of NHS funds should never be influenced by expectations of private gain. GENERAL PRINCIPLES:- any offer or receipt of a gift, hospitality or sponsorship that has been approved must be declared and recorded in the appropriate Register of Gifts, Hospitality and Sponsorship (the Register will be published on the Trust s website); money or gift vouchers should only ever be accepted on behalf of a ward/clinical Service and can only be used for the benefit of that ward/clinical Service through application from the Trust s charitable funds; declare to your employer any relevant interests. If in doubt ask yourself; am I, or might I be, in a position where I (or my family/friends) could gain from the connection between my private interests and my employment? do I have access to information which could influence purchasing decisions? could my outside interest be in any way detrimental to the NHS or patients interests or affect the way taxpayers money is spent? do I have any other reason to think I may be risking a conflict of interest? obtain your line manager s permission before accepting any commercial sponsorship. observe the Trust s Standing Order rules on tendering if you are involved in any way with the purchase of goods and services. REMEMBER Do not accept any inducements, personal gifts of a combined monetary value in total equal to 25 or more, or inappropriate hospitality. (Items of a nominal value or of a promotional nature may be received.) Do not enter into relationships/dealings with Pharmaceutical companies before bringing this to the attention of your line manager (Medical Director for medical staff), in advance. (See section 7.3.3) Do not abuse your past or present official position to obtain preferential rates for private deals. Do not unfairly advantage one competitor over another or show favouritism in awarding contracts. Do not misuse or make available official commercial in confidence information. Do not undertake private work during NHS working hours. Do not engage in outside employment which may conflict with your NHS work. If still unsure seek advice from the Trust Secretary. THE LINE MANAGER ROLE:- To assist Trust employees in complying with this Code, each manager will:- ensure that the Code is brought to the attention of employees for whom they are responsible, and that they are aware of its implications for their work, use the particular systems, policies and procedures associated with the Code, ensure that their employees are aware of the requirement to follow and comply with the procedures which support this Code, and act reasonably and fairly in requiring compliance by employees with the Code. LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 9 of 37

10 3.0 PROFESSIONAL CONDUCT Professional healthcare staff are also reminded of their responsibility for complying with the relevant standards set by their regulatory or professional bodies, eg the GMC s Good Medical Practice, the NMC s Code of Professional Conduct, and the Royal College of Psychiatrists document Good Psychiatric Practice: relationships with pharmaceutical and other commercial organisations. A breach of such standards may lead to action by the Trust, independent of any action taken by the regulatory or professional body concerned. It will be investigated fairly and appropriate steps taken to prevent recurrence and to address any wider issue. 4.0 BUSINESS CONDUCT 4.1 Expectations of Staff 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 service, always ensuring value for money, understand and uphold the Nolan principles to all areas of their work for and on behalf of the Trust. 4.2 Responsibilities of Staff It is also the responsibility of staff to ensure that they do not:- abuse their official position for personal gain or to benefit their family or friends, or seek to advantage or further private business or other interests, in the course of their official duties, or breach any statutory legislation or Trust policies whilst conducting business on behalf of the organisation Staff need to be aware that it is a serious criminal and disciplinary offence to receive or give any gift, loan, fee, or other advantage as an inducement or reward for: undertaking, or refraining from undertaking, anything in their official capacity, or showing favour or disfavour to any person in their official capacity, eg placing a contract for goods or services with a person or organisation. If an allegation of corrupt behaviour is made, staff will have to demonstrate that any rewards they have obtained have not been corruptly obtained. 4.3 Failure to follow/breaches of the Code 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. Failure to follow the Code may damage the Trust and its work and so may be viewed as a disciplinary matter, to be dealt with under normal disciplinary procedures, and LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 10 of 37

11 the penalty could include dismissal. (Please refer to Disciplinary Policy and Procedure.) Staff who are aware about actual breaches of the Code, or who are concerned that there has been, or may be, a breach, should report these concerns to their line manager in the first instance, or direct to the Trust Secretary. In some instances, staff may wish to raise their concerns with the Trust s Freedom to Speak Up Guardian (see section 14). 4.4 Monitoring of the Code The compliance with the Code is monitored through quarterly hospitality returns to the Trust s Compliance Officer, an annual review of hospitality returns by the Trust s Audit and Assurance Committee, and independent reviews undertaken by the Trust s internal audit service. 5.0 CONFLICTS OF INTEREST - GENERAL 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 delivery, 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: 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 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. Interests fall into the following categories: Type Financial interests Non-financial professional interests Description Where an individual may get direct financial benefit from the consequences of a decision they are involved in making. This may be a financial gain, or avoidance of a loss. 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 Where an individual may benefit personally in ways interests 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 LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 11 of 37

12 professional career. Indirect interests Where an individual has a close association 1 with another individual who has a financial interest, a nonfinancial professional interest or a non- financial personal interest and could stand to benefit from a decision they are involved in making. All staff must be aware of how and to whom declarations should be made, declaring material interests at the earliest opportunity (and in any event within 28 days) via a positive declaration to their organisation. Therefore, declarations should be made: On appointment with the organisation When a person moves 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 6. GIFTS AND HOSPITALITY 6.1 Gifts By gifts we mean any item of cash, vouchers, goods, or any service, which is provided for personal benefit, free of charge or at less than its commercial value. The principle of integrity requires that staff should not place themselves under an obligation that might influence, or be perceived to influence the conduct of their duties. In cases of doubt, staff should consult their line manager or politely decline acceptance, drawing the attention of the person making the offer to the existence of this Code. (See Appendix B for flowchart to assist decision making process, and Section 6.3 for declaration process.) Staff must not accept personal gifts with a significant monetary value, or benefits in kind, such as offers of holiday accommodation, under any circumstances Personal gifts must not be solicited under any circumstances Items of nominal value or of a promotional nature given to a wide range of people and not uniquely to the employee, such as free pens, calendars, chocolates, diaries, flow charts and similar items may be accepted. Likewise, gifts of a promotional nature on the conclusion of any courtesy visit to a factory or firm of a sort normally given by the firm may be accepted Long service gifts awarded by the Trust to employees do not require declaration as there is no involvement of a third party. Similarly, other small gifts or awards as determined and awarded at the discretion of the Chief Executive It is often the case that patients and/or their relatives wish to express their thanks to staff with some token gift. Such small tokens of gratitude, below a value of 25, need not necessarily be refused. 1 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. LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 12 of 37

13 6.1.6 There may be a problem over returning a gift, eg a turkey received at Christmas, and therefore consideration should be given to including the gift in a raffle and placing the proceeds into charitable funds An expensive gift should raise a question. The advice of the line manager should be sought. In all cases where a gift is accepted this should be notified in writing (see Appendix C for Registration form) to the Trust Secretary who will enter the notification in the Register In the event that a member of staff is made aware that he or she has been made a beneficiary in a patient s will, the employee should report the matter to his/her line manager and the Trust Secretary, to decide on what steps need to be taken Money and gift vouchers should only ever be accepted on behalf of a Ward/Department and paid into the appropriate charitable fund. When a donation is made, a receipt must be given and the donator must be informed that the donation can only be given for the benefit of the patients and staff at the hospital/site (ie not for individuals). The money/gift voucher, and a copy of the receipt, must be sent to the Accounts Manager for Charitable Funds Officer based within the Finance Department at Trust Headquarters In the event that there is a combination of gifts totalling more than 25 in value, then these should be declined, (except if being received on behalf of a ward or Clinical Service, and paid into the appropriate charitable fund) Any funds raised from activities undertaken on behalf of wards/clinical Services must only ever be used for the benefit of that Ward/Clinical Service and should be paid into the appropriate Ward/Clinical Service charitable fund In order to minimise duplication, it is expected that: Gifts, hospitalities and sponsorships, including when offered to groups of individuals - be reported on to Local Registers Legacies and donations - be reported to Charitable Funds. These will therefore not necessarily require completion of a Registration Form (as at Appendix C), or inclusion into Local Register. 6.2 Hospitality By hospitality we mean meals, refreshments, travel and accommodation offers. Staff should never accept lavish hospitality, or any hospitality which could be interpreted as a way of exerting an improper influence over the way they carry out their duties. There is an expectation that members of staff should receive prior approval from their line manager before accepting an offer of accommodation. Nor should staff offer such hospitality to others on behalf of the Trust. The use of public funds for hospitality and entertainment should be carefully considered. Hospitality must be proportionate as inappropriate or excessive spending can cause lasting damage to the public reputation of the Trust. Hospitality is not the norm when conducting business; it should be provided only when necessary, and with the approval of the budget holder. (See Appendix B for flowchart to assist decision making process, and Section 6.3 for declaration process.) Hospitality must not be solicited under any circumstances. LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 13 of 37

14 6.2.2 Light refreshments (biscuits, tea, coffee and other non-alcoholic drinks) and working meals should only be provided to participants in meetings, if the following criteria are met: the meeting is held in relation to Trust business and attendees are present in that capacity, and lunch is restricted to a buffet or sandwich type meal Other hospitality may be accepted, for instance where:- a member of staff is invited to a Society or Institute Dinner or function, there is a genuine need to impart information or represent the Trust in the community, an event is clearly part of the life of the community or where the Trust should be seen to be represented, and the hospitality concerns attendance at a relevant conference or course where it is clear the hospitality is corporate rather than personal Hospitality must be secondary to the purpose of the meeting/conference. The level of hospitality offered must be appropriate and not out of proportion to the occasion. It should not extend beyond those whose role makes it appropriate for them to attend the meeting Staff should be prepared to be held to account for any hospitality accepted Examples of unacceptable hospitality include:- a holiday abroad or weekend in any holiday centre, offers of hotel accommodation, or tickets for the theatre, shows, concerts, sporting events or other similar types of activities, the use of a company flat or hotel suite, and any of the above being extended to immediate members of the family The timing of hospitality in relation to purchasing or procurement decisions which the Trust may be taking is especially sensitive. It is important to avoid any suggestion of improper influence. Staff are expected to refuse hospitality which might reasonably be seen to compromise their personal judgement or integrity In general terms, it will often be more acceptable to join in hospitality offered to a group than for staff to accept something unique for themselves, eg tickets for the theatre. When a particular person or body has a matter currently in issue with the Trust, eg an arbitration arising from a contract, then clearly common sense dictates that an offer of hospitality be refused even if in normal circumstances it would be regarded as acceptable As a general rule, staff should not accept hospitality which the Trust would not reciprocate in similar circumstances When staff decline hospitality, they should do so in a polite but firm manner and draw the attention of the person making the offer to the existence of this Code. If necessary, staff should pay their share of any costs and claim these from the Trust in the usual way. LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 14 of 37

15 6.3 Process for Notification of Gifts and Hospitality The flowchart at Appendix E gives the process for registering, and the declaration form is at Appendix C. A copy of the generic form is also available on the Trust intranet site or from the Trust Secretary In view of the fact that such matters as the handling of declarations of offers of gifts, hospitality and sponsorship ought to be handled at the point of least centralised competent authority, responsibility for the approval of and recording of such has been devolved to service level, where they will be known as local registers. A list of local register holders is provided at Appendix D At the end of each quarter, all entries received from local register holders will be forwarded to the Trust Secretary, for collation into one Trust-wide Register. This will be submitted to the Audit and Assurance Committee during May of each year. Once approved, this Register of Registers will be made available, under the Trust s Publication Scheme, on the Trust s website. 7.0 SPONSORSHIP 7.1 Definition By this we mean sponsorship offered to staff by external parties who may prospectively seek to contract with that individual and/or the Trust in relation to the commissioning or provision of services. Sponsorship covers:- NHS funding from an external source, including funding of all or part of the costs for a member of staff NHS research (please refer to the Trust s R&D guidelines) Staff training Pharmaceutical company funding Equipment The provision of/funding the hire of meeting rooms Costs associated with meals, gifts and hospitality Hotel and transport costs, (including trips abroad), provision of free services (speakers), building or premises. Publications Sponsored posts Sponsorship should not be accepted from organisations whose major interests are detrimental to the aims of the Trust. No information should be supplied to a company for their commercial gain unless there is a clear benefit to the NHS. During dealings with sponsors there must be no breach of patient or individual confidentiality or data protection rules and legislation. As a general rule, information which is not in the public domain should not normally be supplied. 7.2 Commercial Sponsorship Meetings LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 15 of 37

16 Sponsorship arrangements involving the Trust should be at a corporate, rather than individual, level. 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. The sponsor should not have a dominant influence over the content or the main purpose of the event. Agency / industry representatives organising meetings are permitted to provide appropriate hospitality and/or meet any reasonable, actual costs, which may be incurred. Hospitality must be secondary to the purpose of the meeting. It should not be extended beyond those whose role makes it appropriate for them to attend the meeting. The involvement of a sponsor in an event should always be clearly identified. Any meeting sponsorship must be disclosed in papers relating to the meeting and any published proceedings. Staff 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. The sponsorship if an event should be registered by the Trust lead for the activity using the Registration Form in Appendix C. 7.3 Commercial Sponsorship for Collaborative Partnerships Where collaborative partnerships involve a pharmaceutical company, staff should also be aware of the requirements of Part 14 of the Human Medicines Regulations 2012 ( the Regulations SI 2012/1916), which sets out general definitions relevant to advertising and contains rules on the contents of advertisements and promotions Specific issues may arise where there are opportunities for the Trust or individual employees to enter into co-operative arrangements with pharmaceutical companies. The following guidelines should be observed: the partnership activity should support the overall objectives and priorities of the Trust, these activities should show tangible benefits to individual patient management, the work should support the activities and decisions of the Trust, the overall aim of the partnership should be considered and take account of the need for probity and transparency, the agreement should take account of the programme s clinical effectiveness and of the strict requirements regarding patient confidentiality, any benefits offered or obtained should be documented in the Register, 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. LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 16 of 37

17 7.3.3 Proposed arrangements with pharmaceutical companies must be brought to the attention of your line manager (Medical Director in the case of medical staff) for review prior to agreement If publications are sponsored by a commercial organisation they should have no influence over the content of the publication. The company logo can be displayed on the publication, but no advertising or promotional information should be displayed. The publication should contain a disclaimer which states that sponsorship of the publication does not imply that the Trust endorses any of the company s products or services Commercial sponsorship agreements should always be declared using the Registration Form in Appendix C. 7.4 Commercial Sponsorship for Attendance at Courses and Conferences Acceptance by staff of commercial sponsorship for attendance at relevant conferences and courses is acceptable, but only where the employee seeks permission in advance from their Line Manager/Medical Director, who must be satisfied that acceptance will not compromise purchasing decisions in any way, or if a presentation is being given by the Trust employee, the sponsoring company has had no influence over the presentation s content. Any offer of first class travel or 4/5 star accommodation must be treated very cautiously and is very unlikely to be approved. This should be registered as sponsorship using the Registration Form in Appendix C (Appendix H for medical staff) It is acknowledged that there is a requirement upon medical staff in particular to engage in Continuous Professional Development, for the purposes of maintaining their re-validation On occasions, it may be considered necessary for staff advising on the purchase of equipment to inspect such equipment in operation in other parts of the country (or, exceptionally, overseas). The Trust will want to consider meeting the cost, so as to avoid putting in jeopardy the integrity of purchasing decisions. Staff and their managers should seek advice in advance on such matters from the Trust Secretary. 7.5 Process for the Notification of Sponsorship Acceptance of any offer or receipt of sponsorship must be recorded in the appropriate local register. The same principles will apply as described in Section DECLARATIONS OF INTEREST 8.1 General Staff must ensure that their private or personal interests do not influence their decisions regarding their primary duty to NHS patients, and that they do not use their positions to obtain personal gain of any sort, either for themselves directly, or their families, friends or associates. LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 17 of 37

18 At the earliest opportunity staff must declare any actual or potential conflicts of interest in writing, using the form provided in Appendix G, and send it to the Trust Secretary who will enter the notification in the Trust s Register of Interests. 8.2 Declarations Staff should be meticulous about declaring any actual or potential conflicts of interest as they arise, as affecting themselves, their close family, close friends or associates. (See Appendix F Declaration of Interests flowchart) During the recruitment process for new staff, there is an opportunity to declare any conflicts of interest. If any new interests arise staff must declare in writing (using the pro forma provided in Appendix G) any financial or non-financial interests that they consider could bring about a conflict with the Trust s interests. This declaration should be sent to the Trust Secretary, once signed by the line manager. Such conflicts could typically involve the awarding of contracts to a person or firm, but might be evident in other areas of the Trust s work. Declarations should always be made in cases where any doubt exists. In particular, declarations must be made if any employee:- holds a self-beneficial interest in a private company which may compete for a contract or which may supply a relevant service, for example a nursing home; holds, as a minimum, any shareholdings and other ownership interests in any publicly listed, private for not-for-profit company, business partnership or consultancy which is doing, or might be reasonably expected to do, business with the organisation receives an honorarium for professional services rendered; holds (either individually, or by virtue of their association with a commercial or other organisation), patents or other intellectual property rights please refer to the Trust s Intellectual Property Policy; holds 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; sits 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; are aware that their organisation does business with an organisation in which close family members and relatives, close friends and associates, and business partners have decision making responsibilities. It is not expected that a declaration be made where an interest is purely personal, or relating to family issues that are unconnected to work duties, for example, involvement in offering a case against a school transport consultation. However if the individual is a formal member of a campaign group, it may be prudent to consider recording a declaration. There is no need to declare shares or securities held in collective investment or pension funds or units of authorised unit trusts. 8.3 Strategic decision making groups LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 18 of 37

19 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 (see section 12.2) Selection of medicines, equipment, and devices The Trust s governance arrangements and structures are provided in the Integrated Governance Handbook on Staff esource - Support Services Governance. If a member of staff is present at a Trust Board, Committee or Sub-Committee meeting which is discussing an item which poses a conflict of interest for them, they should declare their interest and leave the meeting room. Any interests so declared will be recorded in the minutes of the meeting. Trust Board Directors are required to declare interests which are relevant and material to the NHS Board of which they are a Director. All existing Trust Board Directors declare such interests and Trust Board Directors appointed subsequently shall do so on appointment. The Trust Secretary will ensure that the Register of Interests is maintained to record formal declarations of interests of Directors, and this information will be published on the Trust s website. 9.0 APPLICATIONS FOR EMPLOYMENT WITHIN THE TRUST Staff involved in making appointments should ensure that these are made on the basis of merit alone. It is unlawful to make an appointment based on anything other than the ability of the candidate to undertake the duties of the post. In order to avoid any possible accusation of bias, staff should not be involved in an appointment where they are related to an applicant, or have a close personal relationship outside work with him or her. Any such relationship should be declared to the line manager, whether or not the employee is involved in the appointment process. Staff should not be involved in decisions relating to discipline, promotion or pay adjustments, or any other employment matter, for any other employee who is a relative, partner, or close personal friend. Candidates making applications for any appointment with the Trust are required to disclose in writing whether, to their knowledge, they are related to any employee of the Trust. Failure to disclose such a relationship may disqualify a candidate and, if he/she is appointed, may render him/her liable to instant dismissal. The Trust s Standing Orders require Directors and every Officer of the Trust to disclose to the Trust Board any relationship with a candidate of whose candidature he/she is aware OUTSIDE EMPLOYMENT/PRIVATE PRACTICE 10.1 General Principles No private work should be carried out during NHS working hours. LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 19 of 37

20 Work undertaken in one s own time, ie not as part of employment within LPT, will need to be declared. (Also be aware that personal indemnity cover may be required, as such work will not be indemnified by the Trust). For instances where a second opinion request is received, please refer to Trust Guidance for requests for Second Opinion Advice (For cases external to LPT) Programmed NHS commitments should always take precedence over private work Staff are advised not to engage in outside employment which may conflict with their NHS work, or be detrimental to it, ie not engaging in activities that would be damaging to reputation, trust or public confidence in health professionals. Staff should seek advice from their line manager if they think they may be risking a conflict of interest in this area, and in any case should declare if in doubt. Staff must declare any actual or potential conflicts of interest using Appendix G, which has been authorised by their line manager and forwarded to the Trust Secretary who will enter the notification in the Trust s Register of Interests. For example, nurses working on the bank of another Trust should inform their line manager to highlight any potential conflict of interest Clinical staff should not initiate conversations about private work with patients during the course of their NHS sessions Clinical staff should not accept direct or indirect financial incentives from private providers other than those allowed by Competition and Markets Authority guidelines Where employees wish to or are asked to undertake lectures or prepare articles/publications outside of their employment with the Trust, the additional question of individuals receiving fees, allowances or royalties may arise. If an individual has made a contribution to a lecture/publication in his/her own time without recourse to using the Trust s resources (for example, stationery, typing, photocopying) then the Trust would view the retention of such fees by the individual as legitimate. In such circumstances, the individual would, of course, be responsible for making an appropriate declaration to the Inland Revenue Where an individual has contributed to a lecture/publication as a by-product of his/her normal working activities and/or undertaken the work during office hours utilising the Trust s facilities, the fee would normally fall payable to the Trust Staff should not use letterheads or business cards employing Trust addresses, telephone, fax numbers or addresses, or advertise their services using these In any cases where doubt exists on the best course of action to adopt, employees are recommended to consult the Trust Secretary who will offer advice on the appropriate course of action Medical Staff LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 20 of 37

21 Medical Staff should be aware of their Terms and Conditions of Service in relation to private practice which should be read in conjunction with the Guidance for LPT Consultant Medical Staff on Private Practice and Fee Paying Services which sets out standards of best practice governing the relationship between NHS work, private practice and fee paying services. Medical Staff should inform their Clinical Manager of any regular commitments in respect of Private Professional Services or Fee Paying Services and should disclose this information at least annually as part of the Job Plan Review MAINTAINING CONFIDENTIALITY 11.1 Standards Expected for Information Confidentiality All employees of the Trust have a duty to maintain confidentiality and the Trust s Information Governance guidance which sets out the general standard to respect confidentiality of information at all times Information about Patients and Clients When patients or clients visit their own doctors, clinics or hospitals, or are visited at home by staff, they give personal details of their lives and allow staff to carry out investigations and record information confident that whatever staff may learn about them will not be reported to unauthorised persons. Staff must not knowingly, wilfully, or by neglect, disclose anything learned about a patient/client to anyone not authorised to receive it Information about Members of Staff When staff are appointed it is necessary to record personal information about them required for record purposes. It is important that this information should also be regarded as confidential and not disclosed to anyone without the prior approval of the employee having first been given Other Confidential Information Staff may find that, as part of their work, they have access to confidential reports and information concerning the business of the Trust and other NHS organisations. The fact that they do have access to this information places a responsibility on them to honour the trust placed on them by the nature of their employment. Commercial in confidence information must not be disclosed to any unauthorised person or organisation as its disclosure would prejudice the principle of a purchasing system based on competition Guidance on Questions of Confidentiality There is seldom any difficulty in deciding when and to whom disclosures of confidential material ought to be made. When any difficulties or doubts arise, however, staff should act cautiously and, depending on the circumstances, approach their line manager for advice Failure to Maintain Confidentiality The intention of the Trust s rules is not to make the Trust and its staff a secretive organisation. As a public body, there is a recognised need for openness. However, this should not be confused with a breach of confidentiality. As employees of the LPT Code of Business Conduct for Trust Staff (Version 5.1 January 2018) Page 21 of 37