DECLARATIONS OF INTERESTS AND POTENTIAL CONFLICTS OF INTERESTS POLICY START DATE: September 2013 NEXT REVIEW: September 2014 COMMITTEE APPROVAL: Executive Team DATE: 14 January 2013 CHAIR S SIGNATURE: ENDORSED BY: Executive Team; Consultative Committee DATE: August 2012 DISTRIBUTION: LOCATION: RELATED DOCUMENTS: AUTHOR / FURTHER INFORMATION: STAKEHOLDERS INVOLVED: Trust-wide Intranet: Trust Policies & Procedures Anti-Bribery and Corruption Policy Bribery Act 2010 Counter Fraud Policy and Response Plan Gifts, Hospitality and Sponsorship Policy Standing Orders Standards of Business Conduct Policy for the Provision of Private Healthcare Sarah Kabirat, Local Counter Fraud Specialist Chief Executive All Directors Non-Executive Directors All Managers All Staff Council of Governors DOCUMENT REVIEW HISTORY: Date Version Responsibility Comments 2 nd March 2012 6 Septemb er 2013 1 Director of Human Resources 2 Director of Corporate Affairs and Company Secretary New Policy in this format replaces conflict of interest policy which also included hospitality. Job titles updated. DATE EXPIRED August 2014 Page 1 of 15
SHORT GUIDE TO THE DECLARATIONS OF INTEREST AND POTENTIAL CONFLICT OF INTEREST POLICY DO: Make sure you are aware of the Trust s Declarations of Interests and Potential Conflicts of Interests Policy and follow it. Make sure if you are responsible for any staff that you understand the Policy, that your staff are made aware of this Policy and where to find it and apply it in your area. Make sure if you are a board director, other director, senior manager or divisional clinical director, consultant, or work in finance, procurement, pharmacy, IT, Estates or Facilities or capital investment that you have a good working knowledge of the policy and follow it. Make sure you seek advice from your line manager in the first instance if you are not sure about the guidance in this Policy. Make sure that you (and your staff) are not put in a position where personal interests may come into conflict with Trust duties. Declare any relevant interests, and if in doubt, ask yourself the following questions: o o o o o Am I, or might I be in a position where I or my family or friends could to gain from the connection between my private interests and my employment? Do I have access to information, or contact with individuals, which could influence purchasing decision? Could my outside interests be in any way detrimental to the NHS, the Trust, or to patients interests? Do I have any reason to think I may be risking a conflict of interest? If after asking these questions you are still unsure Declare it! Inform your line manager if you take on outside work. Raise any concern you may have in relation to fraud or potential bribery offences. DON T: Abuse your official position to obtain preferential rates for private gain. Interview a close personal friend or relative. Unfairly advantage one contractor over another. Show special favour in awarding contracts. CONTENTS Page 2 of 15
1 INTRODUCTION & PURPOSE 4 2 SCOPE 4 3 DECLARATIONS 5 4 BOARD MEMBERS RESPONSIBILITIES 8 5 COUNCIL OF GOVERNORS RESPONSIBILITIES 8 6 RAISING CONCERNS 9 7 FAILURE TO MAKE A DECLARATION 9 8 COMMUNICATION 9 9 MONITORING OF THIS POLICY 9 10 REFERENCES 10 APPENDIX A: DECLARATION OF INTEREST FORM 11 APPENDIX B: RELEVANT AND MATERIAL INTERESTS 14 APPENDIX C: EXAMPLES OF POTENTIAL CONFLICTS 15 Page 3 of 15
DECLARATIONS OF INTERESTS AND POTENTIAL CONFLICTS OF INTERESTS POLICY 1. INTRODUCTION & PURPOSE 1.1 The Trust has a duty to ensure that all its dealings are conducted to the highest standards of integrity and probity and that its Staff, agents, contractors and others, when acting for the Trust in their official capacity, meet these standards. 1.2 This policy aims to ensure that individuals covered by the policy are aware that they must take decisions free from any potential or real situations of undue bias or influence in the decision-making of the Trust. 1.3 It sets out the standards of conduct expected of all Staff where their private interests might conflict with their duties as an employee and the steps the Trust has taken to safeguard itself against potential conflicts of interest. 1.4 Conflicts of interest may arise where an individual s personal, or a connected person s interests and/or loyalties conflict with those of the Trust. The aim of this policy is to protect the Trust and the individuals from any appearance of impropriety which may be a risk to its reputation or a breach of the Bribery Act 2010. 1.5 This policy has been developed in consultation with the Executive Team, Consultative Committee, Pharmacy Department, Estates and Facilities Department and Procurement Department. 1.6 This policy should be read alongside the following Trust policies: Gifts, Hospitality and Sponsorship Policy Counter Fraud Policy and Response Plan Anti Bribery and Corruption Policy Code of Conduct for NHS Managers 1.7 This policy respects the Appointment Commission s Code of Accountability and Code of Conduct for NHS Boards and the seven principles of public life promulgated by the Nolan Committee: Selflessness; Integrity; Objectivity; Accountability; Openness; Honesty; and Leadership. 1.8 Staff should note that this policy does not replace or substitute any professional or other codes of conduct that members of staff or individuals connected with the Trust are obliged to follow. 1.9 This policy replaces and rescinds all previous policies extant within the Trust dealing with the same policy issues. 2. SCOPE 2.1 This policy must be adhered to by all Staff and volunteers, Non-executive Directors and the Council of Governors. 2.2 This includes individuals who are: employed under a contract of employment with the Trust; employed under an honorary contract with the Trust; unpaid volunteers of the Trust; Page 4 of 15
NB. Contracted and third parties (including agency staff) not employed by the Trust but who work at the Trust and/or who exercise functions on behalf of the Trust should also have policies commensurate to this. 3. DECLARATIONS OF INTEREST 3.1 Conflicts of Interest who should declare an interest? 3.1.1 Staff who have an interest in an organisation with which the Trust has a business relationship, for example in an equipment manufacturer or a pharmaceutical company, (or if they have previously worked for such an organisation) may be vulnerable to allegations of impropriety. This also applies to partners, relatives and close associates of that member of staff. 3.1.2 If staff have dealings or interests with external organisations which might influence or be seen by others to influence the Trust s business relationship with that organisation and where a conflict of interest could arise it must be declared using the Declaration of Interest Form which is attached at Appendix A. 3.1.3 The Trust must be told of all cases where a member of Staff, partner, close relative, personal friend or other close associate has a Relevant and Material interest, including significant financial interests. This includes a private company, public sector organisation, other Trust employer or any other company that may compete for an NHS contract to supply goods or services to the Trust. A non-exhaustive list of interests which the Trust considers as relevant and material is listed in Appendix B. 3.1.4 If in doubt about whether a declaration should be made, advice should be sought from your line manager. Staff and Managers are requested to err on the side of caution. The test is that an interest must be declared if it conflicts with your official duties, impairs your abilities to carry out your duties, and/or impacts on your work. A list of further potential conflicts is attached at Appendix C. 3.2 Annual returns 3.2.1 A heavier duty applies to certain groups of staff due to their close involvement in the selection of suppliers and to purchasing decisions. These staff are required to provide an annual declaration return this includes a NIL return where there are no interests to declare. This group includes and is co-ordinated as follows: Group Co-ordinator * Board of Directors Board Governance Manager Council of Governors Board Governance Manager Other Directors, Divisional Directors of Board Governance Manager Operation and Divisional Medical Directors General managers and equivalent Heads of Divisional Directors of Operations Department All procurement staff Head of Procurement Pharmacy Chief Pharmacist Information Technology Director of IT Estates and Facilities staff Head of Estates and Facilities * The named co-ordinator is required to confirm to the Board Governance Manager on an annual basis that the annual declaration has been completed for the staff for which he/she is responsible. Where there are declarations of interest the co-ordinator will ensure that these are completed and sent to the Board Governance Manager. Page 5 of 15
For medical staff the annual declaration will be via the annual appraisal. Doctors will be asked if they have any interests to declare. If yes, a declaration of interest form should be completed which needs to be seen by the appraiser and then sent to the Board Governance Manager. Returns should be made to the Board Governance Manager by the end of April each year for the previous financial year, with the exception of medical staff where returns will be made in year as appraisals occur. 3.2.1 These returns will be co-ordinated by the relevant senior manager for finance, procurement, pharmacy and by the Divisions for consultant medical staff and General managers/equivalent Heads of Department. Other groups will be co-ordinated by the Board Governance Manager. 3.3 Procurement 3.3.1 All staff who participate in tender evaluation panels will be required to make a declaration of interest prior to the commencement of a tender exercise this will include staff who have previously declared an interest. This declaration process will be managed by the procurement directorate. All declarations will be recorded in the tender project file even if no relevant interests are declared. 3.3.2 Any panel member who feels that their personal knowledge, dealings or interests of a tendering organisation would compromise their objectivity should withdraw from the tender evaluation process. 3.3.3 Where it is the opinion of the panel chair that it would be in the interest of the Trust to involve the panel member in the tender evaluation process because of their expertise the extent of their involvement must be recorded in the tender project file notes as an addendum to the Declaration of Interest Form. If the panel chair has any concerns about the involvement of an individual in the tender evaluation process they should seek advice from their procurement representative. 3.3.4 If the previous knowledge or interest is between the panel chair and a tendering organisation, this should be raised with the panel and procurement representative. If it is considered by the panel to be material the member should stand down as chair of the panel and a record made in the tender project file notes as an addendum to the Declaration of Interest Form. 3.3.5 Commercial sponsorship would generally preclude an individual from taking part in a tender panel if the sponsoring organisation were involved. However, where it in the opinion of the director of procurement (in discussion with the relevant medical director) that it would be in the interest of the Trust to waive this rule (for example to obtain the individual s particular expertise) the director of procurement will seek agreement of the director of finance. This decision will be recorded in the tender project file. 3.4 Pharmacy 3.4.1 Staff who present applications for additions to the formulary are required to make a declaration of interest as part of that process. All members of the Prescribing and Formulary committee are asked to make a declaration of interest each time an application is considered by the committee. All declarations are recorded in the minutes of the meeting even if no relevant interest is declared. 3.5 Secondary Employment If any additional work is undertaken and it is felt there is a conflict/ potential conflict of interest with their NHS work, staff must formally declare such employment by using Declaration of Interest Form. See Appendix C for examples of potential conflicts. Page 6 of 15
3.6 Private Practice 3.6.1 Consultants and Associate Specialists (and other relevant medical staff) employed under the Terms and Conditions of Service of Hospital Medical and Dental Staff are permitted to carry out private practice in NHS hospitals subject to the conditions outlined in the handbook "A Code of Conduct for Private Practice Recommended Standards of Practice for NHS Consultants" and the Trusts Policy for the Provision of Private Healthcare. 3.6.2 Consultants and other relevant medical staff must declare any private practice, which may give rise to any actual or perceived conflict of interest, or which is otherwise relevant to their proper performance their contractual duties using the Declaration of Interests Form. They must also declare if they undertake private work as part of the job planning process. 3.6.3 Any private work undertaken during NHS contracted hours may be considered as potentially fraudulent and dealt with in accordance with the Trust s Counter Fraud Policy and Response Plan, and the Disciplinary Procedures. 3.7 Avoiding Conflicts of Interest 3.7.1 In line with section 3.1 staff must avoid placing themselves in situations where they may be vulnerable to allegations of impropriety, and must remove themselves from situations where they risk breaching policy. 3.8 Preferential treatment in Private Transactions 3.8.1 Staff must not seek or accept any benefits from private companies with which they have had or may have dealings with on behalf of the Trust. Every member of Staff has a duty to ensure that they are not put in a position of risk of conflict between private interests and Trust duties. This includes and is not limited to: Goods or services for private use e.g. maintenance work. Payment by business contacts to subsidise social events. Discounts on products with the exception of those offered to all staff through the communications unit. Tickets to cultural or sporting events - with the exception of those offered to all staff through the communications unit. Use of a flat or other accommodation. The offer of a holiday or other similar inducement. 3.9 How to declare an interest? 3.9.1 All Staff on joining are required to declare whether they have an interests and this declaration is held on their personal file in Human Resources. If a declaration of interest is declared the form is also forwarded to the relevant manager and Board Governance Manager. This form is part of the HR joining information and is held by HR. A similar process is applied for volunteers and held by the Volunteers and Work Experience Manager. 3.9.2 If an interest arises subsequently to the completion of the form when joining, staff are required to declare their interests on acquisition of the interest by using the Declaration of Interest Form attached as Appendix A and submit this to the Board Governance Manager. 3.9.3 Staff are responsible for making sure that their registered interests are kept up to date at all times. Although the interest may be declared, this does not remove the member Page 7 of 15
of staff s personal responsibilities for removing themselves from a position or situation which may result in a potential breach of this policy. 3.9.4 The Board Governance Manager will update the Register of Interests and forward the Declaration of Interests Form to: The line manager who is responsible for assessing the significance of interests that have been declared. If as a result of that assessment discussions are required regarding the significance of the interest, the line manager will discuss this with their Director, seeking advice from other relevant Director as appropriate. The line manager must, by return to the Board Governance Manager, acknowledge the declaration of interest and record on the form whether the declaration is acceptable or unacceptable and the action taken. Human Resources, so that a copy can be retained on the staff member s file. 3.9.5 The Register of Interest will be maintained by the Board Governance Manager. 4 BOARD MEMBERS RESPONSIBILITIES 4.1 In addition to the main content of this policy, the following applies to Trust Board Members. 4.2 Board members are required to declare interests which are relevant to the board of which they are a member. This is stated in The Code of Conduct: Code of Accountability in the NHS. Code of Conduct: Code of Accountability in the NHS It is a requirement that chairs and all board directors should declare any conflict of interest that arises in the course of conducting NHS business. All NHS organisations maintain a register of member s interest to avoid any danger of board directors being influenced, or appearing to be influenced by their private interest in the exercise of their pubic duties. All board members are therefore expected to declare any personal or business interest which may influence, or may be perceived to influence their judgement. This should include, as a minimum, personal direct and indirect financial interests and should normally also include such interests of close family members. Indirect financial interests arise from connections with bodies which have a direct financial interest or from being a business partner of or being employed by a person with such an interest. 4.3 Further instructions regarding the duties and obligations of Board Members are detailed in section 6 of the Trust s Standing Orders. 4.4 A register of all Board member interests will be kept and maintained by the Board Governance Manager and will be reviewed by the Trust Board on an annual basis. Interests, however, should be declared as and when they arise, and not only as a result of this annual declaration. 5 COUNCIL OF GOVERNORS RESPONSIBILITIES 5.1 In addition to the main content of this policy, the following applies to the Council of Governors. 5.2 It is a requirement that any governor who has a material interest shall declare such interest to the Board Governance Manager upon joining the Council of Governors. Page 8 of 15
5.3 Further instructions regarding the duties and responsibilities of the governors are detailed in the Roles and Responsibilities of the Council of Governors. 5.4 A register of all of governors interests will be kept and maintained by the Board Governance Manager. However, interests should be declared as and when they arise. 6 RAISING CONCERNS 6.1 Staff that have any concerns relating to a declaration of interest or a private transaction are encouraged to report it to their line manager as soon as possible. 7 FAILURE TO MAKE A DECLARATION 7.1 Should it be suspected that a member of Staff has failed to appropriately declare an interest, or failed to demonstrate compliance with the conduct outlined in this policy, it may be deemed appropriate to take action in line with the Trust s Disciplinary Policy and/or make a referral to the Trust s Local Counter Fraud specialist. 8. COMMUNICATION 8.1 This policy and all associated forms will be made available on the Trust s Intranet or copies of the forms can be requested from the Board Governance Manager. 8.2 This policy will be drawn to the attention of newly appointed staff through new starter information. Reminders to raise awareness on key aspects of this policy e.g. declaration of interest reminders, will be sent via email or otherwise annually by Board Governance Manager. 8.3 Executive directors, other directors and divisional managers and equivalent Staff will have responsibility for implementation and for ensuring that all staff under their direction are made aware of this policy directly. Those departments involved in aspects of procurement will be asked to draw its content to the attention of suppliers and contractors to assure they have commensurate policies in place. 8.4 If staff are in any doubt about matters concerning this policy they should seek advice from their line manager in the first instance. Advice on this policy and its applicability should be directed to the Director of Corporate Affairs and Company Secretary. 9. MONITORING OF THIS POLICY 9.1 The Board Governance Manager will hold the Register of Interests. 9.2 The Register of Interests will record all business and commercial interests declared by Staff. 9.3 The Register of Interests will be subject to an annual review, as part of counter the counter fraud work plan. The outcome of that review will be reported to the Audit Committee. 9.4 The annual review should take into account any significant changes to contracts or suppliers which may have resulted from declarations of interests. 9.5 The above information will be incorporated into an annual review of the policy. Page 9 of 15
10. REFERENCES This Policy has been prepared taking into account the following guidance - NHS Management Executive guidance HSG (93)5 - Standards of Business Conduct for NHS Staff (within this HSG, the Bribery Act 2010 replaces the Prevention of Corruption Acts 1889-1916 ). The Bribery Act 2010 Ministry of Justice Guidance on the Bribery Act 2010 www.justice.gov.uk/bribery.htm NHS Executive Guidance on the Ethical Standards of Commercial Sponsorship (November 2000) The seven Principles of Public Life established by the Nolan Committee (the Nolan Principles) Consultant Contract and Terms and Conditions for Consultants England (2003) The Chartered Institute of Purchasing and Supply Ethical Code The NHS Foundation Trust Code of Governance (Monitor, March 2010) Page 10 of 15
Appendix A DECLARATION OF INTERESTS FORM Please print and complete form as per below: This form should be completed by: - all new Staff - existing staff who hold a relevant and material interest or who consider that their personal interests could constitute a significant conflict of interest. - For a specific group of staff as per 3.2 of this policy, an annual declaration will be requested. DECLARATION I have read and understood the Declarations of Interest and Potential Conflicts of Interests Policy. I understand that failure to abide by this Policy will render me liable for disciplinary action, including termination of employment and investigation by the LCFS that may lead to criminal proceedings being commenced. Please cross out the section which does not apply to you: 1. I do not have any known Conflict of Interest between private interest and my position as an employee of the Chelsea and Westminster Hospital NHS Foundation Trust 2a. I do have a declared Conflict of Interest between my private interest and my position as an employee of the Chelsea and Westminster Hospital NHS Foundation Trust (please complete section 2b. on the next page with details of the nature of your interests) SIGNED (person making declaration) :. DATE: NAME (in CAPITALS): JOB TITLE: DEPARTMENT/DIRECTORATE: Page 11 of 15
Section 2b: Nature and detail of your interest 1 Directorships held in private companies, Public Limited Companies or Limited Liability Partnerships 2 Ownership or part-ownership of private companies, businesses or consultancies 3 Majority or controlling shareholdings 4 Position of authority in a charity or voluntary body 5 Connections with a voluntary or other organisation contracting for or commissioning NHS services 6 Connections with an organisation or Company entering into, or having entered Into a financial arrangement with the Trust 7 Any of the above interests held by a spouse, partner, close relative, other close associates or personal friends 8 Additional Employment There should be no conflict of interest between your duties and any other job. If you have another job and there is a perceived conflict of interest, you must still declare it 9 Any other relevant interests Employer: Post: Date employment began: Hours worked: SIGNED (person making declaration):.. NAME (IN CAPITALS):. DATE:.. Thank you for completing this form. Email completed and signed form to: Board Governance Manager at declarations@chelwest.nhs.uk Registered Date. Page 12 of 15
If declaration is made: Board Governance Manager to forward to Line Manager to Review and Return. I have reviewed the declaration of interest(s) notified above. *I consider the declaration to be acceptable / *I do not consider the declaration to be acceptable and have taken the following action. (*Please delete as applicable)........ Signed Date... Print name Job Title Page 13 of 15
Appendix B Relevant and Material Interests An interest must be declared if it conflicts with your official duties, impairs your abilities to carry out your duties, and/or impacts on your work. The following is a non-exhaustive list of interests which the Trust considers are relevant and material and must be declared: Where an employee works for another organisation, whether NHS related or not; Any directorships of companies likely to be engaged with the business of the Trust; Any role in an organisation which is a supplier or might be a future supplier of the Trust including: o A directorship including a non-executive directorship; o A majority or controlling share holding; o A prospect of future employment. Voluntary or remunerated positions, such as trusteeship, local authority positions, other public positions; Membership of professional bodies or mutual support organisations, including political parties; A position of authority in an organisation in the field of health care. Investments in unlisted companies, partnerships and other forms of business, major shareholdings and beneficial interests; Gifts or hospitality offered to you by external bodies and whether this was declined or accepted in the last twelve months (please refer to the Gifts, Hospitality and Sponsorship Policy for detailed advice); Where a family member or close personal relationship exists with an external body or somewhere where you may be in a position to award services to; A controlling/or significant financial interest in a business which may compete for business at the Trust. A self beneficial interest in a private company that may treat patients of the Trust Any other conflicts that are not covered by the above. Page 14 of 15
Examples of Potential Conflict and how these should be dealt with Appendix C An equipment manufacturer offers to sponsor a clinical post in the Trust. This cannot be accepted if the clinician is required to recommend the sponsor s equipment/product over other clinically appropriate products or any other associated action e.g. withholding information about other suppliers. Sponsorship of this kind can only be considered if recommendation of the equipment (or other associated action) is not part of the agreement and this is clearly and unambiguously stated in writing by the manufacturer - for example our sponsorship shall not require you and/or your organisation to recommend the use of our equipment. A pharmaceutical company offers a clinician starter packs at discounted price. This should be refused but should be declared in order to avoid any suspicion of impropriety and/or that subsequent prescribing of the product might be inappropriately linked to the offer of starter packs. All medicines under all circumstances must enter the Trust through the pharmacy department. It is appropriate for the pharmacy department to consider the use of discounted starter packs in order to make best use of NHS resources. A company offers to provide Training for Trust staff. Training by industry is only acceptable where it is unbiased and has mutual benefit, is evidence based and any hospitality provided is appropriate. Participants must assess whether: 1) they may be influenced unduly for example by providing access to contacts from which a company might benefit in the future. 2) if the training if linked to a specific product that nothing in the arrangement shall require the Trust to recommend, order, purchase or use the product. A clinician wishes to bring a new drug produced by a company with which they have links onto the formulary. The Trust s use of medicines committee requires clinicians who submit applications for new drugs to be added to the formulary to declare their interests as part of the application process. In addition they are asked again to do this at the meeting at which the application is presented. Each committee member is also asked to declare their interests in any application being considered at the meeting. Additions to the formulary are based on clinical and cost effectiveness. Page 15 of 15