The Standards set out how the Independent National Whistleblowing Officer (INWO) expects all NHS service providers to respond when staff raise concerns. This section of the website reviews the expectations for all primary care and contracted services in implementing the Standards.
Listening and responding to concerns raised by staff about the way services are provided is a vital way in which organisations of all sizes can improve their services. In primary care and other small organisations it is particularly important to make this process easy and straightforward, and to show the benefits of raising concerns.
Staff in small teams or organisations can find it particularly difficult to raise concerns about the work they or their colleagues are doing, and it is important that they receive the support and encouragement they need to raise concerns in a way which can improve safe, effective service delivery and good governance.
Senior managers play a critical role in promoting a culture that encourages staff to raise issues or concerns. Their leadership and behaviour will set the tone for the way other staff behave, particularly in a small organisation. All NHS services must strive for a culture that welcomes concerns from people working within their services, whoever they are, and whatever their concern, with the focus on good governance and delivering safe and effective services.
The Standards set out how the Independent National Whistleblowing Officer (INWO) expects primary care providers and contracted services to respond when staff raise concerns, and includes providing support within a culture that welcomes concerns from people working within their services.
Requirement to meet the Standards
All primary care providers and contracted services are required to have a procedure that meets with the requirements of these Standards. This means that any organisation delivering NHS services, whether it is a private company, a third sector organisation or a primary care provider, has the same requirement to ensure access to a procedure in line with these Standards. This includes third sectors organisations providing services on behalf of NHS Scotland and private companies under contract with NHS Scotland, including maintenance and domiciliary services.
All those delivering NHS services must be able to raise concerns about NHS services, and must have access to the support they need to do so. Access to the Standards must be available to:
- anyone who works directly for these services
- anyone working for another organisation, but within these services, such as district nurses, agency staff, students/trainees and volunteers.
If the individual is raising a concern about a service that is not their employer (such as a district nurse working in a GP service or a locum pharmacist working for an agency) then they must be able to raise concerns either directly with their employer or within the service itself, including full access to the Standards.
This includes:
- providing clear information about who staff and other workers can raise concerns with, both within the organisation and externally
- access to a two-stage procedure, where the worker has agreed to use this procedure
- the availability of support for those involved in raising a concern
- arrangements for raising concerns about senior staff
- the requirement to record all concerns
- the requirement to report all concerns internally and to the board on a quarterly basis
- the requirement to share information about how services have improved following raising of concerns, taking care not to reveal who has raised the concern.
Anyone raising a concern about a service provided by NHS Scotland must be signposted to the INWO at the end of this process.
More information about this is available on our page about the independent external review.
When a primary care or contracted service is being delivered by a much larger organisation, such as a local pharmacy that is run by a national company, this company must ensure that any services delivered on behalf of NHS Scotland are compliant with these requirements.
How to raise concerns: options for small organisations
Small organisations face varying challenges around the raising of concerns, and it is important for managers to be aware of these. The most obvious difficulty is for staff to raise concerns in a confidential way, when the size of the team means it will be obvious who has raised the concern. This is likely to be exacerbated by worries that a concern may be investigated by another member of the team.
Small organisations can reduce the difficulties their workers may face in raising concerns by:
- providing an alternative point of contact for raising a concern, for example, sharing ‘confidential contacts’ with other local services or practices. They would not share the details of who had raised the concern, but would act as the person’s advocate, passing on information and updates as appropriate; and
- using an external investigator to investigate concerns raised at stage 2.
To ensure all staff working for NHS providers can safely raise concerns about the services they provide, NHS boards are required to provide a confidential contact for primary care and contracted providers. This person can provide information and advice to anyone considering raising a concern. If necessary the confidential contact will ensure that appropriate action is taken to reduce immediate patient risk.
Where an investigation within the organisation is not possible, due to potential conflicts of interest, the provider must discuss the concern with the NHS board contracting the service, and work with the board to investigate the issue.
For their part, NHS boards must be willing to assist with the investigation of concerns raised in relation to primary care or contracted services. This assistance may involve providing an investigator with an appropriate level of experience and expertise, or advice in how to conduct an investigation. The board must gain assurances that appropriate action has been taken to address concerns raised with them about a service they are providing under contract.
Sharing information about how services have been improved may be more difficult if there is a concern about confidentiality. Care must be taken in reporting both statistical and case specific information. However, where this information can be appropriately anonymised, it provides the potential to reassure staff that their concerns will be listened to and acted on, so every effort must be made to share information in some way.
At the end of this process, the worker must be signposted to the INWO. The INWO's assessment of a case will consider whether the procedures were in line with the Standards, and that sufficient attempts have been made to ensure staff can raise concerns confidentially.
Encouraging staff to raise concerns early is the best way to resolve them easily. It is important, alongside encouraging staff to raise concerns, that they are also given the information they need to raise concerns through the Standards. This must include information on who they can raise concerns with and how, including the board’s confidential contact, as well as any local routes for raising concerns.
They must also be informed of the two stage process and contact details for the INWO, along with information about where they can access information and support on raising concerns. Ensuring this information is readily available will show staff that the organisation values the concerns that they raise.
The detailed information about recording concerns is also applicable to primary care and contracted services.
There is not necessarily a need to have complex recording and reporting systems in place, however, it is important to ensure that there is the capacity to maintain confidentiality for the person raising the concern. This may be achieved by holding information on the person separate from information on the investigation of the concern. Ensuring that access to records is limited to those people for whom access is necessary in relation to the process is critical for compliance with confidentiality and data protection law. Ensuring that those raising concerns are informed of the extent of proposed information sharing before providing their personal information is equally important.
Monitoring, reporting and learning from concerns
The detailed information about monitoring, reporting and learning from concerns is also applicable to primary care and contracted services.
It is important for all services to listen to staff concerns, and for this to lead to learning and service improvements. Learning can be identified from individual cases (including the potential for improvements across other areas of the service) and through statistical analysis of more minor concerns raised at stage 1 of the procedure. Any learning that is identified from concerns must be recorded within the case record, including any action planning.
The number of concerns raised within a single primary care service may be limited, making the outcomes of statistical analysis less valid. For this reason, it is particularly important that primary care services report their concerns data, including lessons learned, to their board. Each board will then be able to collate this information and identify areas for specific attention, based on the themes and trends within the services in their area. On this basis, primary care services must:
- annually report concerns data to the board, even if to report that there were no concerns raised; and
- quarterly only report to the board if concerns were raised in that quarter; if no concerns have been raised, there is no need to report, though it is good practice to let the board know.
Individual services are also expected to show their staff that they value the concerns that are raised by staff and other workers. There are a range of ways they show this, and one of the best ways is to use case studies when concerns have led to improvements. All primary care and contracted services must publish information about the concerns that have been raised with them, unless this is likely to identify any individuals. High level information (with very limited information about what was investigated) may still be appropriate, and will provide the opportunity to show staff that managers will listen and respond to concerns.