Item 11 - Whistleblowing Annual Report
North Lanarkshire Council · 30 November 2022
Back to Health and Social Care Integration Joint Board — 30 November 2022 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 REPORT Item No: 11 SUBJECT: NHS Lanarkshire Whistleblowing Annual Report 2021/2022 TO: North Lanarkshire Integration Joint Board Lead Officer for Report: Ross McGuffie, Chief Officer North HSCP Author(s) of Report Kay Sandilands, Director of Human Resources (NHS Lanarkshire) DATE: 30th November 2022 1. PURPOSE OF REPORT Update members on the application of the National Whistleblowing Standards by NHS Lanarkshire. This paper is coming to the IJB for: For approval For endorsement To note 2. ROUTE TO THE BOARD This paper has been: Endorsed by the NHS Board. Prepared Reviewed Endorsed 3. RECOMMENDATIONS The Integration Joint Board is asked to:- (1) note the NHS Lanarkshire Whistleblowing Annual Report for 2021/20; and (2) note the assurance received by the NHS Lanarkshire Board that whistleblowing standards are being followed and learning shared.
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2 4. VARIATIONS TO DIRECTIONS? 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 The Scottish Public Services Ombudsman fulfils the role of the Independent National Whistleblowing Officer (INWO). The aim of the role is to make sure everyone delivering NHS services in Scotland is able to speak out to raise concerns, ultimately contributing to ensuring that the NHS in Scotland is as well run as possible. 5.2 The INWO developed a set of National Whistleblowing Standards that set out the high level principles and a detailed procedure for investigating concerns. An effective procedure for raising concerns (whistleblowing) is: open focused on improvement objective, impartial and fair accessible supportive to people who raise a concern or are involved in the procedure simple and timely thorough, proportionate and consistent 5.3 The National Whistleblowing Standards and Once for Scotland whistleblowing policy (the Standards) were introduced on 1 April 2021. The Standards are applicable across all NHS services. This means that they must be accessible to anyone working to deliver an NHS service, whether directly or indirectly. 5.4 It is a requirement of the Standards to formally and routinely report whistleblowing performance to NHS Boards, including the preparation of an annual report. 6. CONCLUSIONS 6.1 The NHS Lanarkshire Whistleblowing Annual Report for 2021/20 was presented to the NHS Lanarkshire Board at its meeting of 31st August 2022. At that meeting the NHS Board confirmed that it had received assurance that whistleblowing standards are being followed and learning shared (appended). 6.2 For the purposes of good governance and transparency, this Annual Report is being shared with the IJB completeness. Yes No N/A
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3 7. IMPLICATIONS 7.1 NATIONAL OUTCOMES Link(s) to National Health and Wellbeing Outcomes People are able to look after and improve their own health and wellbeing and live in good health for longer People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonable practicable, independently and at home or in a homely setting in their community People who use Health and Social Care Services have positive experiences of those services, and have their dignity respected Health and Social Care Services are centred on helping to maintain or improve the quality of life of people who use those services Health and Social Care Services contribute to reducing health inequalities People who provide unpaid care are supported to look after their own health and wellbeing, including to reduce any negative impact of their caring role on their own health and wellbeing People who use Health and Social Care Services are safe from harm People who work in Health and Social Care Services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide Resources are used effectively and efficiently in the provision of Health and Social Care Services 7.2 ASSOCIATED MEASURE(S) None. 7.3 FINANCIAL None associated with this report. This paper has been reviewed by Finance: Yes No N/A
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4 7.4 RISK ASSESSMENT/RISK MANAGEMENT Whistleblowing is not currently on the IJB risk register. 7.5 PEOPLE 7.5.1 All those working in Health and Social Care Partnerships can raise concerns about NHS services, whoever their employer is. Any concerns about the delivery of NHS services must be handled in line with the requirements of these Standards, and anyone raising a concern through these Standards can do so to INWO. 7.5.2 If staff do not have confidence in the fairness of the procedures through which their concerns in respect of NHS services are raised, or do not feel assured that concerns raised will be acted upon, there is a risk that they will not raise valid concerns about quality, safety or malpractice. The opportunity to investigate and address these concerns will have been lost, with potentially adverse impact on quality, safety and effectiveness of services. There is also a wider risk to organisational integrity and reputation, if staff do not believe they will be listened to and do not feel senior leaders in NHS Lanarkshire are fulfilling the organisation’s values and promoting a culture of psychological safety. The activity described within this report contributes to the mitigation of such risks. 7.6 INEQUALITIES & FAIRER SCOTLAND DUTY EQIA Completed & Fairer Scotland Impact Assessment Form Completed: Yes No N/A 8. BACKGROUND PAPERS NHS Lanarkshire Whistleblowing Annual Report – April 2021 to March 2022 (see appendix 1)
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5 9. APPENDICES Appendix 1: NHS Lanarkshire Whistleblowing Annual Report – April 2021 to March CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact Ross McGuffie on telephone number 01698 752 591. Members seeking further information about any aspect of this report, please contact the following; Name: Kay Sandilands, Director of Human Resources (NHS Lanarkshire) Phone: 01698 752865 Email: Kay.Sandilands@lanarkshire.scot.nhs.uk
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6 Appendix 1: Whistleblowing Annual Report – April 2021 to March 2022 1. Introduction The National Whistleblowing Standards and Once for Scotland whistleblowing policy (the Standards) were introduced on 1 April 2021. NHS Lanarkshire’s performance against the Key Performance Indicators included in the Standards has been reported to the Staff Governance Committee and the board on a quarterly basis. In addition to quarterly reporting boards are also required to prepare an annual report, the contents of which are outlined in the Standards. 2. Key Performance Indicators 2.1 Cumulative total – Whistleblowing Concerns Raised 2021/22 Quarter Appropriate for whistleblowing Stage 1 Stage 2 Outcome Comments 1 1 0 1 Upheld Action plan implemented 2 0 n/a n/a n/a 3 2 (1 appropriate for WB and unnamed. 1 partially appropriate for WB) 1 1 Both mainly upheld. 1 complaint was unnamed and mainly upheld. The second complaint was dealt with under 2 procedures – WB and a separate HR procedure. The latter complaint was mainly upheld at stage 1 4 0 0 0 n/a Total 3 1 2 The Standards require stage 1 concerns to be completed within 5 working days and Stage 2 concerns to be completed within 20 working days. The table below shows the number and percentage of concerns at each stage which were closed in full within the set timescales of 5 and 20 working days, for 2021/22. This reflects any extensions agreed.
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7 Nos received % closed in 5 working days Nos received % closed in 20 working days Stage 1 2 100 Stage 2 1 100 The table below shows concerns raised in 2021/22 where an extension was authorised. Concern Nos received Extension authorised As % of all concerns Stage 1 2 1 50 Stage 2 1 1 100 3. Analysis of numbers of concerns raised Three concerns were raised during 2021/22 and this compares to two during 2020/21, two during 2019/2020, one during 2018/19, three during 2017/18 and none during 2016/17, so numbers remain fairly constant. It would be interesting to compare NHS Lanarkshire’s numbers with those from other Boards but this information is not readily available, unless the Independent National Whistleblowing Officer (INWO) decides to publish national numbers, which would be useful for comparison purposes. 4. Further information on the 3 concerns raised during 2021/22, including service improvements and shared learning. 4.1 The first complaint raised in April 2021 was reported to the Staff Governance Committee in September 2021 and concerned one of the radiology departments. Specifically, concerns were raised about staff rest areas, staffing numbers, management support, enhanced information around incident reporting and wider sharing of departmental protocols, particularly around out- of-hours services. A detailed action plan was developed as a result of this concern being raised and staff have been intrinsic to its development. The agreed actions included a commitment to work on workforce planning, ensuring staff involvement and feedback on progress; consideration of available space for rest areas; reviewing management support within the department including senior management visibility; enhancing information sharing around incident reporting; wider sharing of departmental protocols to improve the patient care journey, particularly out of hours and to develop a departmental action plan which could be shared with all staff. The action plan has been largely monitored through local departmental management meetings and has also been discussed at pan Lanarkshire service meetings, which are attended by clinical leads for all departments, the service manager and team and director and associate medical director. This has enabled learning and service improvements to be shared across the sites. The action plan will also be tabled at the acute divisional management team to log issues and note progress and has been a regular feature at the site departmental monthly staff meetings. This has ensured that staff are aware of the points raised and that outcomes and learning are shared. Specific learning
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8 and quality improvement projects have been generated around some of the themes in the action plan and, in addition to local discussion, these projects have been shared across all of the radiology departments and via the site clinical governance groups. A short life working group has continued ongoing work including use of the workforce planning tool and an SBAR. Locums were contracted to work in radiology to provide additional cover until 8pm and at weekends on an interim basis. A staff well-being hub has been established on the three sites supported by a well-being rep, notice board and signposting. Well-being is a standard item on monthly staff meetings. Management have been attending safety huddles, departmental staff meetings and ensuring a presence across departments. Quality improvement projects have been completed on MRI safety and radiology patient flow and a safety group established to discuss Datix. Overnight Datix incidents are shared and discussed on site daily huddles. The action plan is a standing agenda item at monthly staff meetings where minutes of the groups outlined above and updated actions are shared. 4.2 The second complaint raised concerned cleaning services at one of the acute hospitals where cleaning services are managed by a private contractor. The concern was raised in October 2021 and followed on from a previous and similar complaint raised in December 2020, which was before the introduction of the new Standards. The investigation upheld a number of the issues which had been identified and concluded by providing eight detailed assurance recommendations. These recommendations related to: Appropriate use of equipment Cleanliness of equipment Staff training in relation to domestic sign off sheets and food hygiene documentation Helpdesk sign off processes Process for re-auditing Approach to contract management of soft FM services Need for a root cause analysis of issues highlighted to identify specific improvement actions. An action plan, based on the investigation report and recommendations, was developed by the contractor, in conjunction with the Property & Support Services Division (PSSD). Its aim was to address the issues identified and embed the necessary changes in the contractor’s approach to service delivery. An evidence portfolio to support the implementation of the action plan was compiled and shared with the management team in PSSD through the ongoing monitoring process for Soft FM services at the hospital concerned. The learning and recommendations from the report were also shared with the PSSD team responsible for delivery of PFI contract management services at both University Hospital Hairmyres and University Hospital Wishaw, in order to ensure that learning generated from the issues identified and the subsequent recommendations were reflected across the estate.
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9 The implementation of the action plan was monitored through weekly senior level operational management meetings and also through fortnightly senior management meetings established by the Director of Planning, Property & Performance with PSSD and the contractor. These groups continue to meet to review the performance of the healthcare cleaning service at the hospital concerned, which is subject to daily auditing by the NHS Lanarkshire Facilities Management Team auditor. The Director of Planning, Property and Performance also presented a report to the Healthcare Quality Improvement and Assurance Committee (HQAIC) where there was a high level of engagement from Board members. 4.3 The third complaint concerned culture and behaviours within one of the departments of the HR directorate. Prior to this particular issue being raised the Head of Service had already commissioned a piece of work following a decrease in iMatter scores and a mediation session was held in December 2021 which highlighted a number of areas for improvement. The subsequent investigation into the whistleblowing concern also made a number of recommendations on areas to improve the culture and behaviours within the team. These formed the basis of an action plan which focussed on improving communication, clarifying roles, equitable workload and consistency in application of policies/procedures. The head of service has held three sessions with the staff to take forward the action plan and feedback to date suggests that the culture within the department is improving. The action plan is fluid and will be amended as required, with the aim of achieving an overall improvement in relationships within the team. Implementation of the action plan is monitored by the HR director on a monthly basis and staff have been involved in the process throughout and have driven the development and content of the plan. Key learning outcomes which have been shared across the team include the importance of role clarity, regular and timely communication, two-way feedback and an environment where it is safe to speak up. These learning outcomes were carefully reviewed with a view to potentially sharing them across the directorate. It was concluded that, for reasons of confidentiality as part of the complaint was dealt with under a separate HR policy, this would not be appropriate. The complaint was also reported to the Staff Governance Committee. 5. Whistleblowing themes, trends and patterns The analysis of themes from whistleblowing concerns aids identification of any shared causes and helps to progress learning and improvement in a targeted manner. The categories/classification for whistleblowing concerns are listed in Part 2 of the Standards and are outlined below for information: Patient Safety Patient Care Poor practice Unsafe working conditions Changing or falsifying information on performance
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10 Fraud Breach/breaking any legal obligation Abusing authority Concealment of any of the above Interrogation of the three complaints raised does not initially reveal any obvious thematic concerns, with each being quite distinct and classification covering a number of the categories listed above i.e. patient safety, patient care, poor practice, unsafe working conditions and changing or falsifying information on performance. However, it should be noted that, with regard to the second complaint about cleaning standards, a very similar complaint had previously been raised in October 2020, which was prior to the introduction of the Standards. The actions outlined above and the thorough and high level of scrutiny by the appropriate governance committee (HQAIC) reflect the fact that two very similar complaints had been received, both of which concerned patient safety. 6. Independent primary care contractors A reporting template and targeted communications were developed for independent primary care contractors. Out of those that returned the reporting template, none had received any whistleblowing complaints. It is, however, worth noting that a complaint was received from a GP practice in April 2022 and this will be reported in the quarter 1 report for 2022/23. 7. Experience of Individuals Raising Concern/s during 2021/22 The experience of the individual who raised the concern about radiology services was reported as very positive. No feedback was received from the other two individuals who raised concerns. A further indicator of the satisfaction of those who raise concerns can be derived from the number of concerns escalated to the INWO and no referrals were made to the INWO as a result of concerns raised in NHS Lanarkshire. 8. Communication, Awareness and Training Since the soft launch of the Standards at the beginning of 2021 regular items have appeared in the staff briefing and in the Pulse on-line. Details of confidential contacts have been publicised and a separate briefing has also been sent to all primary care contractors, along with supporting documentation to enable independent contractors to record and report cases. The non-executive whistleblowing champion has presented to the two Health & Social Care Partnerships and Acute management teams and presentations have also been made to both the GP and GDP Sub Committees. Meetings have also been held with both PFI contractors to confirm that the Standards will be made available to their staff who provide services to NHS Lanarkshire patients and the non- executive whistleblowing champion has delivered presentations to the PFI management teams at University Hospitals Hairmyres and Wishaw. Managers in PSSD have been asked to circulate leaflets on whistleblowing for staff who do not have easy access to email. The HR page on FirstPort includes information on whistleblowing, including details of how to raise concerns via the uMatter email address. Further communications have been issued, including items in the staff briefing in September 2021 and January 2022,
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11 emails about the INWO webinars and a video recorded by the non-executive whistleblowing champion. This video appeared with links to social media and the INWO. Training on the Standards is available through TURAS via two modules and NES provides monitoring information on the uptake of the training. To date the training module for all staff has been completed by 151 people and the module for managers/people receiving complaints has been completed by 52 people. It is acknowledged that the numbers completing the training modules are lower than anticipated and directors have now been contacted about this in a bid to increase the uptake of training. 9. Confidential Contacts There are seven confidential contacts in NHS Lanarkshire, all of whom have completed the training modules. Their contact details are regularly publicised in briefings and in the Pulse on line and they are also available on NHS Lanarkshire’s intranet. Two of the confidential contacts are designated for private contractors, including PFIs and one is designated specifically for independent primary care contractors. A network for the confidential contacts has been established to enable them to meet with the Non- Executive Whistleblowing Champion and the HR Director on a bi-annual basis. They are also encouraged to engage with the Scottish Speak Up Network. Priorities for 2022/23 During 2022/23 it is intended to focus on the following areas: 1. Continuing to publicise the Standards and ways to raise concerns. 2. Broadening awareness across independent primary care contractors and encouraging more engagement with data reporting requirements. 3. Developing organisational culture to focus on values and behaviours, leadership and management development, metrics and data and people processes. The work on people processes is yet to be scoped but may include capturing concerns staff may have in relation to the workplace or services such as the use of whistleblowing procedures. 4. Explore the possibility with the Scottish Government of including reference to whistleblowing in iMatter or of developing another national survey which would assist in gauging the level of awareness across the organisation. 5. Use the INWO’s Speak Up week in October to further promote and celebrate speaking up. 10. Conclusion The Board is asked to note the implementation update and the content of this performance report and seek assurance that whistleblowing standards are being followed and learning shared. Kay Sandilands Director of Human Resources July 2022