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Speaking up: Raising concerns policy

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  • Policy owner: Freedom to speak up guardian
  • Corporate lead: Director of workforce, OD and system development
  • Date approved by Joint Negotiating Consultative Forum(JNCF): July 2024
  • Date ratified by Trust Leadership team: July 2024
  • Date issued: July 2024
  • Next review date: July 2025

Executive summary

This document sets out Leeds Community Healthcare NHS Trust’s (the trust) freedom to speak up (formerly called whistleblowing) policy and procedures and supersedes the earlier version of the policy which was issued in July 2018.

The policy incorporates current experience and learning from speaking up at the trust.

The policy has been written to comply with the statutory requirements of the Public Interest Disclosure Act (PIDA) 1998, as amended in the Enterprise and Regulatory Reform Bill, and the revised NHS Constitution published March 2013. It also
incorporates the standard integrated freedom to speak up policy produced by NHS Improvement and NHS England in April 2016, following the recommendations of the review by Sir Robert Francis into whistleblowing in the NHS.

The policy is based on the June 2022 NHS England policy guidance

This policy applies to all workers within the trust which includes those who are within a bank or locum system or via an agency. This policy also extends to those who may hold an honorary contract with the trust, are independent contractors to the trust or work in the trust as volunteers.

This policy must be read together with other relevant trust policies, procedures and local guidance, such as the acceptable standards of behaviour policy, the grievance policy, the discipline policy, the local anti-fraud, bribery and corruption policy and local safeguarding standards and guidance for children and adults.

The policy and procedures may be reviewed at the request of management or staff side by giving four weeks’ written notice with reasons for the review.

The policy was updated in January 2024 and will be reviewed in July 2024 and will seek advice and learning from staff who speak up to develop new learning and ways of work.

Table of content

  1. Introduction
  2. Speaking up is a practice not a position
  3. Speaking up
  4. Confidentiality
  5. Who can raise concerns?
  6. Who can I raise a concern with?
  7. Freedom to speak up guardian and champions
  8. National Guardian office
  9. Making a protected disclosure
  10. Monitoring and compliance
  11. Equality analysis
  12. Appendices

1. Introduction

The speaking up policy at Leeds Community Healthcare NHS Trust enables all staff to speak up at the earliest possible opportunity.

Speaking Up is welcomed at Leeds Community Healthcare. It helps the trust to see issues, hear staff concerns and create positive change. It supports the trust to provide the best care for patients and communities, address health inequalities and create the best culture for all our staff.

The policy aligns with our seven behaviours of the trust.

  • Caring for our patients
  • Making the best decisions
  • Leading by example
  • Caring for one another
  • Adapting to change and delivering improvements
  • Working together
  • Finding solutions

This policy therefore aims to:

  • enable workers to feel confident in raising concerns
  • provide a way for those concerns to be raised
  • ensure that a response is made to all concerns and to raise awareness of how to pursue concerns if dissatisfied
  • give reassurance that protection against recrimination or victimization will be provided
  • encourage staff to raise concerns with the trust so that they may be addressed

2. Speaking up is a practice not a position

Leeds Community Healthcare NHS Trust has a cultural approach called speaking up is a practice not a position. This means that there are several speaking up channels at the trust. Staff are encouraged to use any of these channels to ensure their voice is heard. Speaking up is what we all do and enable.

The mechanisms are:

  • managers and colleagues
  • easy access to senior managers and directors
  • ask the CEO anonymous Q and A on the trust intranet
  • Trade unions
  • Workforce department (HR)
  • Freedom to speak up guardian
  • Race equality network speaking up champions
  • Local counter fraud specialist (for fraud issues): Audit Yorkshire. All concerns about possible fraud should be reported to the local counter fraud specialist or director of finance.

Appendix 1 contains key contact details.

We ask all staff to complete the online training about speaking up. The online module on listening up is for managers to complete and the module on following up is for senior leaders to
complete.

Watch the videos explaining speaking up

3. Speaking up

Speaking up about any concern you have at work is vital. It will help us to keep improving our services for all patients and the working environment for our staff. Raising concerns can be difficult. In accordance with our behaviours and Duty of
Candour, our senior leaders and entire board are committed to an open and honest culture. We will look into what you say and offer support. Staff should suffer no detriment for raising a genuine concern.

You can raise a concern about risk, malpractice, poor experiences, or wrongdoing you think is harming the service we deliver. A few examples of this might include (but are by no means restricted to):

  • Unsafe patient care
  • Unsafe working conditions
  • Inadequate induction or training for staff
  • Lack of, or poor, response to a reported patient safety incident
  • Suspicions of fraud (which should be reported to our local counter-fraud specialist or the director of finance)
  • A bullying or non-supportive culture
  • Staff or manager behaviours that conflict with our trust vision, values, and behaviours

The trust is committed to a culture of transparency and fair treatment of all. It will challenge strongly any harassment or victimization of anyone raising a concern. We will not tolerate any attempt to bully employees into not raising any such concern. Such behaviour is a breach of our values as an organization and our behavioural standards and, if upheld following investigation, could result in disciplinary action.

Provided you are acting honestly, it does not matter if you are mistaken or if there is an innocent explanation for your concerns. A staff member will not face repercussions or lose their job for speaking up.

When you raise a concern, it will be shared with the Chief Executive, relevant directors and senior leaders in the service concerned and a plan of response and if need be, investigation will occur. The person who spoke up will be kept informed as this happens. If an investigation is needed timelines will be established for an orderly and responsive process. Where an investigation is needed, this will be objective and conducted by someone who is suitably independent (this might be someone outside your organisation or from a different part of the organisation) and trained in investigations. Feedback to the staff member and from the staff member is a key part of this process. We will thank the staff member or members who speak up. As an organization we will learn and share learning across the trust.

The most important aspect of your speaking up is the information you can provide, not your identity.

You have a choice about how you speak up:

  • Openly: You are happy that the person you speak up to knows your identity and that they can share this with anyone else involved in responding.
  • Confidentially: You are happy to reveal your identity to the person you choose to speak up to on the condition that they will not share this without your consent.
  • Anonymously: you do not want to reveal your identity to anyone. This can make it difficult for others to ask you for further information about the matter and may make it more complicated to act to resolve the issue. It also means that you might not be able to access any extra support you need and receive any feedback on the outcome.

There will be regular reporting to the trust board and two papers presented by the freedom to speak up guardian to the board annually. A review of how staff experience speaking up in the trust also takes place.

4. Confidentiality

We hope you will feel comfortable raising your concern openly, but we also appreciate that you may want to raise it confidentially. This means that while you are willing for your identity to be known to the person you report your concern to, you do not want anyone else to know your identity. Therefore, we will keep your identity confidential if that is what you want, unless required to disclose it by law (for example, by the police or a court) or if it involves a crime or harm to a person.

5. Who can raise concerns?

Anyone who works (or has worked in the last two years) for the trust. This includes bank, locum or agency workers, temporary workers, students, honorary contract holders, independent contractors, volunteers and trainees.

6. Who can I raise a concern with?

In many circumstances the easiest way to get your concern resolved will be to raise it formally or informally with your line manager or lead clinician. Where you don’t think it is appropriate to do this, you can use any of the internal options set out below:

  • Head of service
  • Your trade union representative
  • Your clinical supervisor
  • Any member of the Human Resources team
  • Your head of profession
  • The freedom to speak up guardian
  • Freedom to speak up champions
  • Executive directors
  • Non-executive director responsible for speaking up (email Helen Thomson via helen.thomson15@nhs.net)

If you do not want to speak up to someone within your organisation, you can speak up externally to:

  • Care Quality Commission (CQC) for quality and safety concerns about the services it regulates, you can find out more about how the CQC handles concerns.
  • NHS England for concerns about:
    • GP surgeries
    • Dental practices
    • Optometrists
    • Pharmacies
    • How NHS trusts and foundation trusts are being run (this includes ambulance trusts and community and mental health trusts)
    • NHS procurement and patient choice
    • The national tariff

    NHS England may decide to investigate your concern themselves, ask your employer or another appropriate organisation to investigate (usually with their oversight) and/or use the information you provide to inform their oversight of the relevant organisation. The precise action they take will depend on the nature of your concern and how it relates to their various roles. Please note that neither the Care Quality Commission nor NHS England can get involved in individual employment matters, such as a concern from an individual about feeling bullied.

  • NHS Counter Fraud Authority for concerns about fraud and corruption, using their online reporting form or calling their freephone line 0800 028 4060. If you would like to speak up about the conduct of a member of staff, you can do this by contacting the relevant professional body such as the General Medical Council, Nursing and Midwifery Council, Health and Care Professions Council, General Dental Council, General Optical Council or General Pharmaceutical Council

7. Freedom to speak up guardian and champions

This is an important role identified in the Freedom to Speak Up Review to act as an independent and impartial source of advice and support to staff at any stage of raising a concern. The Freedom to Speak Up Guardian can support a staff colleague to speak up and raise the concern if the employee feels they cannot step forward and speak openly. This enables concerns to be heard.

The trust’s freedom to speak up guardian is:

There are Speaking Up Champions linked to the trust Race Equality Network. The champion’s role is to offer supportive conversations, share information and signpost.

The contact email for the champions is lcht.ren@nhs.net

If you remain concerned after this, you can contact:

Jenny Allen and Laura Smith, Director of Workforce, OD and System Development, our executive directors with responsibility for raising concerns

If for any reason you do not feel comfortable raising your concern internally, you can raise concerns with external bodies

You can also contract the whistleblowing helpline for the NHS and social care, accessible via the NHS and Social Care whistleblowing helpline on: 08000 724 725

For speaking up via the freedom to speak guardian a staff member or members would approach the guardian. A confidential and supportive conversation will be offered which will offer support to the staff member and explore what they wish to be raised and the best ways to raise this. If a formal concern via the freedom to speak guardian is chosen by the staff member, the guardian will raise with the chief executive and relevant directors and senior managers. Such concerns can be in the person’s name or non-identified. The guardian will assist the trust to hear and understand the concern. The trust will look at the concern and seek to look at the concern via an investigation or other route. The staff member will be kept informed as things progress. Once the concern is finished the guardian will close the case.

If a staff member contacts the guardian or champions and it isn’t a speaking up concern the guardian and champions will signpost to the right service in the trust.

8. National Guardian office

The national guardian office can independently review how staff have been treated having raised concerns where NHS trusts and foundation trusts may have failed to follow good practice. You can contact the National Guardian by telephoning
0191 249 4400 (Monday to Friday from 10am to 2pm) or accessing the National Guardian website.

9. Making a protected disclosure

A protected disclosure is defined in the Public Interest Disclosure Act 1998. This legislation allows certain categories of worker to lodge a claim for compensation with an employment tribunal if they suffer as a result of speaking up. The legislation is complex and to qualify for protection under it, very specific criteria must be met in relation to who is speaking up, about what and to whom. To help you consider whether you might meet these criteria, please seek independent advice from the whistleblowing helpline for the NHS and social care, Public Concern at Work, now called at Protect or a legal representative.

The following agencies most relevant to the NHS are detailed below:

10. Monitoring and compliance

The Workforce directorate is responsible for this policy and will review its effectiveness annually. They will also monitor the daily operation of the policy. If you have any comments or questions, please do not hesitate to let one of their team know.

The Quality Committee is responsible for ensuring organizational learning arising from disclosures made under the policy. This will be facilitated by bi-annual reports from the director of workforce.

11. Equality analysis

Leeds Community Healthcare NHS Trust’s vision is to provide the best possible care to every community. In support of the vision, with due regard to the Equality Act 2010 General Duty aims, Equality Analysis has been undertaken on this policy and any outcomes have been considered in the development of this policy. The screening template is attached as appendix 2

12. Appendices

12.1 Appendix 1 Contact details

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