Standards of business conduct policy

Document control:

Policy name: Standards of business conduct policy
Policy number: C002
Version: 1.0
Status: Final – approved
Policy lead: Associate Director of Governance
Responsible Executive Director: Executive Director of Corporate Services
Responsible Committee: Audit, Risk and Compliance Committee
Date Approved by Responsible Committee: 5 March 2026
Date ratified by EICB Board: 1 April 2026
Next review date: April 2027
Target audience:
-Essex Integrated Care Board (EICB) members and staff (including temporary/bank/agency/ voluntary/work experience staff).
– Contractors engaged by the ICB.
-Staff from other Essex Integrated Care Partnership (ICP) organisations who are members of EICB committees/sub-committees and other groups.
Stakeholders engaged in development of policy (internal and external):
– Governance Team
– Kevin Edwards, Associate Director, Attain.
– Director of Pharmacy, Medicines and Clinical Policies
– Staff Engagement Group.
– Staff Side
– ICB Executive Team
– Audit Committee
Impact assessments undertaken: Equality Impact Assessment (see Appendix A)

Version history:

Version: 0.1
Date: 03/02/26
Author (Name and title): Michael Watson
Summary of amendments made: First draft

Version: 0.2
Date: 20/06/23
Author (Name and title): Sara O’Connor
Summary of amendments made: Draft policy added to agreed EICB policy template and other updates

Version: 1.0
Date: 05/03/26
Author (Name and title): Governance Senior Officer
Summary of amendments made: Final – Approved version

Introduction

This is a controlled document. Whilst this document may be printed (please consider if this is necessary), the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the website (or requested from the Governance Lead/Team) to ensure the most up-to-date version is used.

The Standards of Business Conduct policy describes the standards and public service values which underpin the work of the NHS and reflects current guidance. Effective management of conflicts of interest is crucial to give confidence to patients, taxpayers, healthcare providers and Parliament that ICB commissioning decisions are robust, fair, transparent, and offer value for money. ICBs are also required under the NHS Act 2006 (as amended by the Health and Care Act 2022) to manage conflicts of interest.

The major focus of this policy is the management of conflicts of interest and is intended to ensure that Essex Integrated Care Board (‘the ICB’) complies with NHS England’s ‘Managing Conflicts of Interest in the NHS’ guidance (September 2024) which considers changes introduced by the Health and Care Act 2022, specifically the establishment of Integrated Care Boards and the introduction of the Provider Selection Regime.

Decision-making must be geared towards meeting the ICB’s statutory duties, including the ‘triple aim’. Any individual involved in decisions relating to ICB functions must be acting clearly in the interests of the ICB and of the public, rather than furthering direct or indirect financial, personal, professional or organisational interests.

ICBs were created to give statutory NHS providers, local authority and primary medical services nominees a role in decision-making. These individuals will be expected to act in accordance with the first principle (as described in paragraph 1.3 above), and whilst it should not be automatically assumed that they are personally or professionally conflicted just by virtue of being an employee, director, partner or otherwise holding a position with one of these organisations, the possibility of actual and perceived conflicts of interests arising will remain. For all decisions, ICBs will need to carefully consider whether an individual’s role in another organisation could result in actual or perceived conflicts of interest and whether that outweighs the value of the knowledge they bring to the process.

The personal and professional interests of all ICB board members, ICB committee members and ICB staff who are involved in the marking of decisions within this ICB need to be declared, recorded and managed appropriately. Declarations must be made as soon as practicable after the person becomes aware of the conflict or potential conflict and, in any event, within 28 days of the person becoming aware. This includes being clear and specific about the nature of any interest, and about the nature of any conflict that may arise regarding a particular decision.

If an interest is declared but there is no risk of a conflict arising, then no further action need be taken (although this will still need to be recorded). However, if a material interest is declared, then it should be considered to what extent this material interest affects the balance of the discussion and decision-making process. In doing so the ICB should ensure conflicts of interest (and potential conflicts of interest) do not, (and do not appear), to affect the integrity of the ICB’s decision making processes.

ICBs should consider the composition of decision-making forums and should clearly distinguish between those individuals who should be involved in formal decision taking, and those whose input informs decisions. ICBs should consider the perspective the individual brings and the value they add to both discussions around particular decisions and in actually taking part in the decision including the ability to shape the ICB’s understanding of how best to meet patients’ needs and deliver care for their populations. The way conflicts of interests are managed should reflect this distinction. For example, where independent providers (including the voluntary, community, faith and social enterprise (VCFSE) sector) hold contracts for services it would be appropriate and reasonable for the body to involve them in discussions, for example about pathway design and service delivery, particularly at place-level. However, this would be clearly distinct from any considerations around contracting and commissioning, from which they would be excluded.

Actions to mitigate a conflict of interest should be proportionate and should seek to preserve the spirit of collective decision-making wherever possible. Mitigation should take account of a range of factors including the perception of any conflicts and how a decision may be received if an individual with a perceived conflict is involved in that decision, and the risks and benefits of having a particular individual involved in making the decision. Potential options in relation to mitigation are outlined in section 6.25.24 below.

Including a conflicted person in the discussion but not in decision making;
Excluding a conflicted person from both the discussion and the decision making;
Including a conflicted person in the discussion and decision where there is a clear benefit to them being included in both – however, including the conflicted person in the actual decision should be done after careful consideration of the risk and with proper mitigation in place. The rationale for inclusion should also be properly documented and included in minutes.
Excluding the conflicted individual and securing technical or local expertise from an alternative, unconflicted source

This policy, in conjunction with the ICBs Procurement and Contracting Policy, elaborates on these principles, explaining the processes to be followed in order to maintain them.

The way conflicts of interest are declared and managed should contribute to a culture of transparency about how decisions are made. In particular when adopting a specific approach to mitigate any conflicts of interest (including perceived conflicts) ICBs should ensure that the reason for the chosen action is documented in minutes or records.

These factors should be read in conjunction with other relevant NHSE statutory guidance, including guidance on the Provider Selection Regime and guidance on joint working and delegation arrangements. In relation to the Provider Selection Regime, as is already established practice in the NHS, where decisions are being taken as part of a formal competitive procurement of services, any individual who is associated with an organisation that has a vested interest in the procurement should recuse themselves from the process.

Purpose

The purpose of this policy is to ensure that the ICB maintains the highest standards of probity and that all business relationships lead to clear benefits for patients, and intends to:

(a) Enable the ICB to deliver its statutory duty to manage conflicts of interest
(b) Enable individuals to demonstrate that they are acting fairly and transparently and in the best interest of patients and the local population
(c) Uphold confidence and trust in the NHS
(d) Safeguard commissioning, whilst ensuring objective decision-making
(e) Support individuals to understand when conflicts of interest (whether actual or potential) may arise and how to manage them if they do
(f) Ensure that the ICB operates within the legal framework.
(g) Uphold the reputation of the ICB and its staff in the way it conducts business

Scope

This policy applies to, including and without limitation, whether permanent, temporary, seconded, students/trainees/apprentices or contracted-in (either as an individual or through an agency/third party supplier):

all ICB staff members and those of hosted organisations
members of the Board, committees/sub-committees and practice representatives involved in the ICB’s policy-making processes (including co-opted members, appointed deputies, temporary appointments, members of committees/groups from other organisations and ‘regular attendees’ of these meetings.
self-employed consultants.

Some individuals are more likely than others to have a decision-making role or influence on the use of public money because of the requirements of their role. In the context of this policy, the officers listed below are referred to as ‘decision making officers’:

Board and sub-committee members
Place based directors
Executive and senior managers as outlined in the Scheme of Reservation and Delegation and Standing Financial Instructions
Level 4 Patient and Public Voice partners

Definitions and categories of interests

Commercial Sponsorship – An arrangement where the ICB receives financial support or support in kind for staff, research, training, equipment, premises or conferences.

Conflict of Interest – 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 delivering, 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, or
Potential – there is the possibility of a material conflict between one or more interests in the future.

Individuals 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 imputation of improper conduct.

‘Interests’ can arise in a number of different contexts. A benefit may arise from the making of a gain or the avoidance of a loss.

Financial interest – Where an individual may get direct financial benefit (this may be a financial gain, or avoidance of a loss) from the consequences of a decision they are involved in making.

Gifts – Any item of cash or goods, or any service, which is provided for personal benefit, free of charge or less than its commercial value.

Hospitality – Food, drink, travel, accommodation, or entertainment offered or provided in the nature of the organisation’s business by anyone other than the employer.

‘Material interest’ – is an interest which a reasonable person would take into account when making a decision regarding the use of taxpayers’ money because the interest has relevance to that decision. Consequently, all such interests should be declared and assessed as appropriate for inclusion in the ICB’s register of interests.

Non-financial professional interest – 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 interests – Where an individual may benefit personally in ways 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 professional career.

Indirect interests: Where an individual has a close association with another individual who has a financial interest, a non-financial professional interest or a non-financial personal interest and could stand to benefit from a decision they are involved in making. These associations may arise through relationships with close family members and relatives, close friends and associates, and business partners. A common-sense approach should be applied to these terms. It would be unrealistic to expect staff to know of all the interests that people in these classes might hold. However, if staff do know of material interests (or could be reasonably expected to know about these) then these should be declared. Further guidance on how to interpret these categories can be found in Appendix B.

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.

Decision-Making Staff: Those staff in roles who are more likely than others to have a decision-making influence on the use of taxpayers’ money, because of the requirements of their role. The ICB considers decision-making staff to be:

Executive, non-executive and partner members of the ICB Board (or equivalent roles) who have decision making roles which involve the spending of taxpayers’ money (equivalent roles in different organisations carry different titles and these should be considered on a case-by case basis).
Members of advisory groups which contribute to direct or delegated decision making on the commissioning or provision of taxpayer funded services.
Staff at Agenda for Change band 8d and above (reflecting guidance issued by the Information Commissioner’s Office with regard to freedom of information legislation).
Administrative and clinical staff who have the power to enter into contracts on behalf of their organisation.
Administrative and clinical staff involved in decision making concerning the commissioning of services, purchasing of goods, medicines, medical devices or equipment, and formulary decisions.

Improper Performance: Under the Bribery Act 2010 improper performance is defined in summary as ‘performance which amounts to a breach of an expectation that a person will act in good faith, impartially, or in accordance with a position of trust.’ The offence applies to bribery relating to any function of a public nature, connected with a business, performed during a person’s employment or performed on behalf of a company or another body of persons. Therefore, bribery in both the public and private sectors is covered by the Act.

NB: It is an offence for a person to offer, promise or give a financial or other advantage to another person in one or two cases:

Case One applies where that person intends the advantage to bring about the improper performance by another person of a relevant function or activity or to reward such improper performance.

Case Two applies where the person knows or believes that the acceptance of the advantage offered, promised, or given in it constitutes the improper performance or a relevant function or activity.

Joint Working – Situations where, for the benefit of patients, organisations pool skills, experience and/or resources for the joint development and implementation of patient centred projects and share a commitment to successful delivery. Joint working agreements and management arrangements are conducted in an open and transparent manner.

Joint working differs from sponsorship, where pharmaceutical companies simply provide funds for a specific event or work programme.

Openness – Means that there should be transparency about NHS activities to promote confidence between the ICB and its employees, service users and the public.

Pharmaceutical Industry – Includes:

Companies, partnerships or individuals involved in the manufacturing, sale, promotion or supply of medicinal products subject to the licensing provision of the Medicines Act 196816.
Companies, partnerships or individuals involved in the manufacture, sale, promotion or supply of medical devices, appliances, dressings, and nutritional supplements which are used in the treatment of patients within the NHS.
Trade associations and agencies representing companies involved with such products.
Companies, partnerships or individuals who are directly concerned with research, development or marketing of a medicinal product, device, appliance, dressing or supplement that is being considered by, or would be influenced by, decisions taken by the ICB.
Pharmaceutical industry related industries, including companies, partnerships or individuals directly concerned with enterprises that may be positively or adversely affected by decisions taken by the ICB.

Probity – Means that there should be an absolute standard of honesty in dealing with the assets of the NHS. Integrity should be the hallmark of all personal conduct affecting service users, employees, and suppliers and in the use of information acquired in the course of NHS duties.

VCFSE – Voluntary, community, faith and social enterprise.

Roles and responsibilities

ICB Board

In the context of this policy members of the Board are:

required to comply with all relevant elements of this policy
ensure that the ICB’s policies and procedures reflect best practice particularly in relation to the procurement of services
ensure that arrangements for audit and reporting are open, robust and effective.

Chief Executive

The Chief Executive Officer of the ICB has overall accountability for managing conflicts of interest within the ICB and is responsible for:

ensuring that the ICB has processes in place to enable individuals to declare and manage conflicts of interest.
creating a culture in which ICB employees feel able and supported to report any conflicts of interest concerns as part of their day-to-day activities.

Executive Director of Corporate Services

The Chief Executive has delegated responsibility for the organisation’s compliance with this policy to the Executive Director of Corporate Services including investigation into any breaches of this policy.

Audit, Risk and Compliance Committee

The Audit, Risk and Compliance Committee will have responsibility for

Overseeing the arrangements for the management of conflict of interest, gifts, hospitality and commercial sponsorship, and advise the Board as required.
Receive a Decision Register report on a quarterly basis which will include all decisions made by the Board and Board Committees inclusive of any declaration of interests made against each decision and how those conflicts were managed.
Ensure that the registers of interests and gifts, hospitality and sponsorship are reviewed regularly and updated as necessary.
Ensure that for every interest declared, arrangements are in place to manage the conflict of interests or potential conflict of interests, to ensure the integrity of the ICB’s decision making process.
The arrangements will confirm the following:
When an individual should withdraw from a specified activity, on a temporary or permanent basis.
Monitoring of the specified activity undertaken by the individual, either by a line manager, colleague or other designated individual.

Conflicts of Interest Guardian

The Chair of the Audit, Risk and Compliance Committee will be the ICB’s Conflict of Interest Guardian and, in collaboration with the ICB Governance Lead, will:

Act as a conduit and safe point of contact for staff, members of the public and healthcare professionals who have any concerns with regards to conflicts of interest.
Be a safe point of contact for employees or workers of the ICB to raise any concerns in relation to this policy, ensuring that concerns are treated with appropriate confidentiality and that explanations are provided for any decisions taken.
Support the rigorous application of this and associated policies.
Provide independent advice and judgement to staff and members where there is any doubt about how to apply conflicts of interest policies and principles in an individual situation.
Provide advice on minimising the risks of conflicts of interest.

Contact details for the Audit, Risk and Compliance Committee Chair/Conflicts of Interest Guardian are at Appendix D.

Policy Author

The policy author will have responsibility for reviewing and updating the policy in line with Section 9 below.

Associate Director of Governance (ICB Governance Lead)

The ICB Governance Lead, with the support of other governance team staff, is responsible for:

Ensuring the ICB has a conflicts of interest policy in place which is accessible to staff.
Ensuring a formal review of all individuals’ declarations of interest is undertaken annually.
Providing staff and other relevant individuals with advice, support, and guidance to enable them to manage conflicts of interest.
Maintaining the register of interest, register of gifts and hospitality and other records relating to the management of conflicts of interest
Ensuring that registers of interest and registers of gifts and hospitality are published on the ICB’s public website.
Ensuring that appropriate administrative arrangements are in place to effectively manage and record/report any issues relating to breaches of this or associated policies.
Supporting the Conflicts of Interest Guardian to enable them to effectively carry out their responsibilities.
Maintain the Decision Register of all decisions made by the Board and Board Committees inclusive of any declarations made against each action, provide to Audit, Risk and Compliance Committee meetings on a quarterly basis and subsequently published on the ICB public website, unless exempt due to reasons of commercial sensitivity or personal confidentiality.
Ensuring that senior managers provide adequate, appropriate and transparent reporting to the ICB Board, its committees, stakeholders and the public as required by the Health and Social Care Act 2012 and the Health and Care Act 2022.

Executive Director of Finance and Commercial

The Executive Director of Finance and Commercial is a designated contact to whom any suspicious of fraud may be reported, as per the Counter Fraud, Bribery and Corruption Policy, and is also the lead Executive Director for procurement.

Line Managers

Line managers are responsible for upholding and promoting high standards in relation to the management of conflicts of interest, gifts, hospitality and commercial sponsorship, ensuring staff reporting to them understand their responsibilities and are supported to adhere to the requirements of this policy and for providing adequate, appropriate and transparent reporting to the ICB Board and its committees, stakeholders and the public.

Line managers should be the first point of contact if a member of staff is unsure whether to declare an interest or to accept/decline a gift and should work with their staff to ensure their declarations of interests and declarations of gifts and hospitality are up to date, including during annual appraisal of members of their team.

Local Counter Fraud Specialist

The ICB Local Counter Fraud Specialist should be contacted in the first instance if you have any genuine suspicions or concerns over fraud or bribery, in accordance with the ICB Counter Fraud Bribery and Corruption Policy.

The LCFS is responsible for investigating allegations of fraud, bribery, and corruption. In consultation with the Executive Director of Finance and Commercial, the LCFS will report any case to the NHS Counter Fraud Authority and / or the police, as agreed, in accordance with the NHS Counter Fraud manual. The LCFS is responsible for taking forward all counter fraud work locally in accordance with national standards and in consultation with the Executive Director of Finance and Commercial.

All ICB Employees, Committee members and Contractors.

The ICB uses the skills of many different people, all of whom are vital to our work. This includes people on differing employment terms, who for the purposes of this policy are collectively referred to as ‘staff’ and are listed below:

All Board members and salaried employees.
All prospective employees who are part-way through recruitment.
Contractors and sub-contractors.
Agency/bank staff.
Committee, sub-committee and advisory group members (who may not be directly employed or engaged by the organisation, for example staff employed/engaged by member organisations of the Essex Integrated Care Partnership).

As a member of staff you should:

Familiarise yourself with this policy and associated policies, including the Counter Fraud and Bribery and Corruption Policy and follow them.
Refer to NHSE/I guidance on managing conflicts of interest for the rationale behind this policy.
Use your common sense and judgement to consider whether the interests you have could affect the way taxpayers’ money is spent.
Regularly consider what interests you have and declare these as they arise. If in doubt, declare. (NB: There may be occasions where staff declare an interest but upon closer consideration it is clear it is not material and so does not give rise to the risk of a conflict of interest. The governance lead/team will decide whether it is necessary to transfer such declarations to the ICB’s registers of interests).
Seek clarification from your line manager on any points which are not clear.
Speak up if you have any concerns about how conflicts of interest are being managed.
Support others to identify and manage conflicts of interest.
Undertake mandatory online conflicts of interest training.
Report any suspicions of fraud, bribery, or corruption in accordance with the ICB’s Counter Fraud, Bribery, and Corruption Policy by referral to the ICB’s Local Counter Fraud Specialist (LCFS), Executive Director of Finance and Commercial, or to the NHS Counter Fraud Authority (NHS CFA).

As a member of staff you should not:

misuse your position to further your own interests or those close to you.
be influenced or give the impression that you have been influenced by outside interests.
allow your outside interests to inappropriately affect the decisions you make when using taxpayers’ money.

Standards of business conduct

Principles of good business conduct

The ICB expects Board and committee members, staff, contractors and all involved in the business of the ICB to observe the principles of good governance in how they do business. These include:

In addition, as an ICB we will:

Do business appropriately: conflicts of interest become much easier to identify, avoid and/or manage when the processes for needs assessments, consultation mechanisms, commissioning strategies and procurement procedures are right from the outset, because the rationale for all decision-making will be clear and transparent and should withstand scrutiny.
Be proactive, not reactive: commissioners should seek to identify and minimise the risk of conflicts of interest at the earliest possible opportunity.
Be balanced and proportionate: rules should be clear and robust but not overly prescriptive or restrictive. They should ensure that decision-making is transparent and fair whilst not being overly constraining, complex or cumbersome.
Be transparent: document clearly the approach and decisions taken at every stage in the commissioning cycle so that a clear audit trail is evident.
Create an environment and culture where individuals feel supported and confident in declaring relevant information and raising any concerns.

The ICB recognises that:

A perception of wrongdoing, impaired judgement or undue influence can be as detrimental as them actually occurring.
If in doubt, it is better to assume the existence of a conflict of interest and manage it appropriately rather than ignore it.
For a conflict of interest to exist, financial gain (including avoidance of loss) is not necessary.

The ICB understands the requirement to consult upon major changes before decisions are reached and will be open with the public, patients and staff. Information supporting decisions will be made available in a way that is understandable. Responses to requests for information in accordance with the Freedom of Information Act 2000 will be provided in this spirit.

Our business will be conducted in a way that is socially responsible, forging an open and positive relationship with the local community and in consideration of the impact of the organisation’s activities on the environment.

Identification & declaration of interests

‘Interests’ can arise in several different contexts. A material interest is one which a reasonable person would take into account when making a decision regarding the use of taxpayers’ money because the interest has relevance to that decision.

The definition of ‘conflict of interest’ and the types/categories are defined in Section 4 above and within the Declaration of Interest Form at Appendix B. A common-sense approach should be applied to these terms. It would be unrealistic to expect staff to know of all the interests that people in these categories might hold. However, if staff do know of material interests (or could be reasonably expected to know about them) then these should be declared.

Staff may hold interests for which they cannot see any potential conflict. However, caution is always advisable because others may see it differently. It will be important to exercise judgement and to declare such interests where there is otherwise a risk of imputation of improper conduct.

Conflicts of interest can arise in many situations, environments and forms of commissioning, with an increased risk in primary care commissioning, out-of-hours commissioning and involvement with integrated care organisations, as clinical commissioners may here find themselves in a position of being at once commissioner and provider of services. Conflicts of interest can arise throughout the whole commissioning cycle: from needs assessment to procurement exercises, to contract monitoring.

All staff must identify and declare material interests at the earliest opportunity, and by law within 28 days after the interest arises/is known. The ICB also expects individuals to declare new interests they are pursuing.

Declarations received may be checked against publicly accessible sites including those hosted by Companies House, Disclosure UK, and social media – with particular focus being directed to Board members and other individuals holding decision making roles within the ICB. The annual audit of conflicts of interest will also include checks against random sample declarations of interests.

If staff are in any doubt as to whether an interest is material, they should declare it, or seek advice from the Governance Lead so it can be considered.

Declarations should be made, using the declaration of interest form available at Appendix B and as a separate document on the ICB’s intranet, as below:

On appointment with the organisation, or as a member of an ICB committee/sub-committee or other group/forum – the ICB will implement appropriate arrangements to facilitate this.
Annually when prompted by the ICB and/or during the staff appraisal process. Because of its role in spending taxpayers’ money, the ICB will ensure that, at least annually, staff are prompted to update their declarations of interests or make/confirm a nil return where there are no interests or changes to declare.
During meetings by inclusion of declarations of interest as a standing item on each meeting’s agenda.
All board or committee members are required to declare any interests in agenda items in advance of the meeting. The Governance Team will assist with identification of relevant interests. During Board and other meetings, members/attendees are required to declare their interests as a standing agenda before the item is discussed. Even if an interest has been recorded in the register of interests, it should still be declared in meetings where matters relating to that interest are discussed. Declarations of interest and how they were managed must be recorded in minutes of meetings.
If a specialist or expert is invited to comment on a meeting paper in order to help the committee or group with their discussions, that individual must be asked to complete a declaration of interest.
When staff move to a new role or their responsibilities change significantly.
At the beginning of a new project/piece of work/procurement process/contract monitoring: Conflicts of interest must be managed appropriately throughout the whole commissioning cycle and then within the ongoing management of existing contracts. You must complete a declaration of interest form at the outset of any commissioning process, even if you have nothing to declare, and a record of this should be made available to relevant stakeholders as per the ICB policy around register of interests. Where a potential conflict of interest has been identified, you must take steps to declare this as soon as possible and work with the commissioning lead and/or the Governance Lead to agree the extent to which it is appropriate for you to be involved in the ongoing process and, in some circumstances, whether it is appropriate to be involved at all. Similarly, should your circumstances change at any point during the commissioning cycle, you must declare any potential conflict of interest as soon as possible and follow steps identified in this policy.

Please also refer to the ICB’s Procurement and Contracting Policy which has specific requirements for managing conflicts of interest.

Whenever an individual’s role, responsibility or circumstances change in a way that affects the individual’s interests (e.g. where an individual takes on a new role outside the ICB or enters a new business or relationship), a further declaration must be made to reflect the change in circumstances as soon as possible, and in any event within 28 days. This could involve a conflict of interest ceasing to exist or a new one materialising. The onus is on the individual to make this declaration, rather than waiting to be asked

Where an interest is declared, the individual’s line manager should review the form and agree any mitigating action required to manage any conflicts which should be recorded on the form for transferring to the appropriate register.

Declarations of Interest forms submitted outside of recruitment processes should be returned to the Governance team for inclusion on the register of interests.

After expiry, an interest will remain on register(s) for a minimum of six months and a private record of historic interests will be retained for a minimum of six years.

Appointment of board members, committee members and senior employees.

On appointment of board members, committee members and senior employees, the ICB will consider whether conflicts of interest should exclude individuals from being appointed to the relevant role. This will be considered on a case-by-case basis, with advice being sought from the Conflicts of Interest Guardian. In relation to any committees or sub-committees exercising ICB commissioning functions, and in compliance with the ICB Constitution – approval and appointment of members to such committees or sub-committees will be made by the ICB chair.

The ICB will assess the materiality of the interest, particularly whether the individual (or any person with whom they have a close association) could benefit (whether financially or otherwise) from any decision the ICB might make.

The ICB will determine the extent of the interest and the nature of the appointee’s proposed role within the ICB. If the interest is related to an area of business significant enough that the individual would be unable to operate effectively and make a full and proper contribution in the proposed role, the individual will not be appointed to the role.

Any individual who has a material interest in an organisation which provides, or is likely to provide, substantial services to an ICB should recognise the inherent conflict of interest risk that may arise and should not be a member of the Board or of a committee or sub-committee of the ICB. This is applicable if the nature and extent of their interest and the nature of their proposed role is such that they are likely to need to exclude themselves from decision-making on so regular a basis that it significantly limits their ability to effectively perform that role.

Additionally, the ICB constitution specifically prohibits appointment of individuals to the ICB board, committees or sub-committees if the appointment could reasonably be regarded as undermining the independence of the health services because of the candidate’s involvement with the private healthcare sector or otherwise.

This would prevent, for example, directors of private healthcare companies or significant stakeholders of private healthcare companies from sitting on any board, committee or sub-committee exercising ICB commissioning functions.

However, employees/directors of voluntary organisations, social enterprises, and GPs and other clinicians may be appointed as members of the ICB board, committees or sub-committees provided they are not regarded as undermining the independence of the health services.

Proactive Review of Interests

The ICB will require all staff to formally review and, if necessary, update their declaration of interest annually.

Reminders for staff to review and update their declarations of interest will be provided in several ways, including reminders based on the anniversary of the last declaration and via the staff appraisal process.

The ICB will implement arrangements to prompt ICB Board members and other decision-making staff to review and update their declarations of interest on a regular basis by:

Including ‘declarations of interest’ on meeting agendas.
Providing a register to each meeting of the ICB Board and its main committees/groups setting out the interests of relevant members and regular attendees.
Implementing arrangements to ensure that staff participating in projects, new pieces of work and procurement processes are required to declare relevant interests.

Maintenance of records

The ICB will maintain the following registers:

All declared interests that are material will be promptly transferred to the register by the Governance team.

Where the ICB is participating in a joint committee, any interests which are declared by the committee members should be recorded on the register(s) of interest of each participating organisation.

Publication

The ICB will publish the interests declared by decision-making staff in the relevant registers available on the ICB website.

This information will be refreshed at least annually.

Registers of interests for publicly held Board or committee meetings will be made available within meeting papers available on the ICB website.

Registers will also be made available for inspection, by emailing [email protected] to make an appointment with the Governance team, at Seax House, Victoria Road South, Chelmsford, Essex CM1 1QH.

If decision-making or other staff have substantial grounds for believing that publication of their interests should not take place, they should contact the ICB Governance Lead to explain why. In exceptional circumstances, for instance where publication of information might cause the member of staff or somebody else substantial damage or distress or put a member of staff at risk of harm, with the agreement of the Conflicts of Interest Guardian (who will seek appropriate legal advice where required), information may be withheld or redacted on public registers. However, this would be the exception, and information will not be withheld or redacted merely because of a personal preference. In these circumstances a confidential unredacted record will be maintained.

Wider transparency initiatives

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. These “transfers of value” include payments relating to:

Speaking at and chairing meetings.
Training services.
Advisory board meetings.
Fees and expenses paid to healthcare professionals.
Sponsorship of attendance at meetings, which includes registration fees and the costs of accommodation and travel, both inside and outside the UK.
Donations, grants and benefits in kind provided to healthcare organisations.

Further information about the scheme can be found on the ABPI website.

Management of interests – General

The ICB will manage interests sensibly and proportionately. Each case will be different. The general management actions listed below, along with relevant industry/professional guidance should complement the exercise of good judgement. It will always be appropriate to clarify circumstances with individuals involved to assess issues and risks.

If an interest is declared but there is no risk of a conflict arising then no action is warranted. However, if a material interest is declared then the general management actions that could be applied include:

Restricting staff involvement in associated discussions and excluding them from decision making.
Removing staff from the whole decision-making process.
Removing staff responsibility for an entire area of work.
Removing staff from their role altogether if they are unable to operate effectively in it because the conflict is so significant.

Each case will be different and context-specific, and the ICB will always clarify the circumstances and issues with the individuals involved to assess issues and risks. Staff should maintain a written audit trail of information considered and actions taken.

Staff who declare material interests should make their line manager or the person(s) they are working to aware of their existence.

The ICB Governance Lead and/or the Conflicts of Interest Guardian will provide advice on possible disputes about the most appropriate management action to ensure that interests do not (and do not appear to) affect the integrity of the ICB’s decision-making process

Managing conflicts of interests at meetings

The chair of a meeting of the ICB’s Board or any of its committees, sub-committees or groups has ultimate responsibility for deciding whether there is a conflict of interest and for taking the appropriate course of action to manage the conflict.

The chair, with support of the ICB’s Governance Lead or their representative, should proactively consider ahead of meetings what conflicts are likely to arise and how they should be managed, including taking steps to ensure that supporting papers for particular agenda items of private sessions/meetings are not sent to conflicted individuals in advance of the meeting where relevant. This also applies to the minutes of discussions held relating to relevant item(s).

On circulation of the meeting agenda, delegates should be asked to confirm in writing prior to the meeting whether they believe themselves to be conflicted or potentially conflicted regarding one or more of the agenda items.

The chair should ask at the beginning of each meeting if anyone has any conflicts of interest to declare in relation to the business to be transacted at the meeting. Each member of the group should declare any interests which are relevant to the business of the meeting, whether or not those interests have previously been declared. Any new interests declared at a meeting must be notified to the Governance Team for inclusion on the ICB’s register of interests to ensure it is up-to-date.

Any new offers of gifts or hospitality (whether accepted or not) which are declared at a meeting must be included on the ICB’s register of gifts and hospitality to ensure it is up-to-date.

It is the responsibility of each individual member of the meeting to declare any relevant interests which they may have. However, should the chair or any other member of the meeting be aware of facts or circumstances which may give rise to a conflict of interests, but which have not been declared, then they should bring this to the attention of the chair who will decide whether there is a conflict of interest and the appropriate course of action to take in order to manage the conflict of interest.

Declarations of interest in respect to board and committee meeting agenda items should be declared at the time the agenda and papers are circulated to enable the chair to plan how any conflicts should be managed at the meeting.
Perceptions of conflicts of interests should be considered even if an actual conflict does not exist: if there is perception of a conflict of interest, the individual should consider recusing themselves from the meeting.
On reviewing the committee or board agenda and accompanying papers, members should inform the chair and secretariat of details on the specific agenda items and the type of conflict

Interests that have previously been declared should also be included in the pre-meeting declaration. There is no need for partner members to make a general statement regarding the fact that they are practicing local clinicians or professionals. However, if their status in that role places them in conflict regarding a specific agenda item then they should state this, along with the type of interest, as listed above.

Managing conflicts when making joint decisions with other partners.

Conflicts of interest management is important in the context of joint decision-making processes, especially working with local partners, other ICBs or NHSE to jointly commission services. promising the ICB’s ability to make robust commissioning decisions.

Appropriate governance arrangements must be put in place that ensure that conflicts of interest are identified and managed. Where independent providers (including the voluntary sector) hold contracts for services (for example, community services) it would be appropriate and reasonable for the body to involve them in discussions (for example, about pathway design and service delivery, particularly at place-level). However, this would be clearly distinct from any considerations around contracting and commissioning, from which they would be excluded.

The chair of the meeting has ultimate responsibility for deciding whether there is a conflict of interest and for taking the appropriate course of action, in order to manage the conflict of interest.

When a member of the meeting (including the chair or deputy chair) has a conflict of interest in relation to one or more items of business to be transacted at the meeting, the chair (or deputy chair or remaining non-conflicted members where relevant as described above) must decide how to manage the conflict. The appropriate course of action will depend on the circumstances but could include one or more of the following:

Chairing by non-conflicted member – Where the chair has a conflict of interest, deciding that the deputy chair (or another non-conflicted member of the meeting if the deputy chair is also conflicted) should chair all or part of the meeting
Not attend – Requiring the individual who has a conflict of interest (including the chair or deputy chair if necessary) not to attend the meeting.
Not receive papers or minutes – Ensuring that the individual concerned does not receive the supporting papers or minutes of the meeting which relate to the matter(s) which give rise to the conflict.
Leave discussion – Requiring the individual to leave the discussion when the relevant matter(s) are being discussed and when any decisions are being taken in relation to those matter(s). In private meetings, this could include requiring the individual to leave the room and in public meetings to either leave the room or join the audience in the public gallery.
Partial attendance – Allowing the individual to participate in some, or all, of the discussion when the relevant matter(s) are being discussed but requiring them to leave the meeting when any decisions are being taken in relation to those matter(s). This may be appropriate where, for example, the conflicted individual has important relevant knowledge and experience of the matter(s) under discussion, which it would be of benefit for the meeting to hear, but this will depend on the nature and extent of the interest which has been declared.
Remain and participate – Noting the interest and ensuring that all attendees are aware of the nature and extent of the interest but allowing the individual to remain and participate in both the discussion and in any decisions. This is only likely to be the appropriate course of action where it is decided that the interest which has been declared is either immaterial or not relevant to the matter(s) under discussion. The conflicts of interest case studies include examples of material and immaterial conflicts of interest.

At the start of meetings, the chair should summarise all interests received prior to the meeting and call for any other interests in respect of the agenda items. Just prior to individual agenda items being discussed, the chair should confirm any declarations of interest referred to earlier in the meeting. The chair, in discussion with meeting attendees if appropriate, should agree on a course of action to manage those conflicts. This very much depends on an assessment of the facts at the time but several options are available to the chair of the meeting:

Ask the individual to leave the meeting when the agenda item on which an individual is conflicted is discussed.
Allow the individual to take part in the discussion but leave the meeting when the decision is made.
Note the interest but allow them to take part in the discussion and the decision making.

Details on how individual conflicts of interest were managed should be reflected in the minutes of the meeting. Examples of where it may be appropriate to exclude the public include:

Information about individual patients or other individuals which includes sensitive personal data is to be discussed.
Commercially confidential information is to be discussed, for example the detailed contents of a provider’s tender submission.
Information in respect of which a claim to legal professional privilege could be maintained in legal proceedings is to be discussed.
To allow the meeting to proceed without interruption and disruption.

Minutes of meetings

If any conflicts of interest are declared or otherwise arise in a meeting, the chair must ensure the following information is recorded in the minutes:

Who has the interest?
The nature of the interest and why it gives rise to a conflict, including the magnitude of any interest.
The items on the agenda to which the interest relates.
How the conflict was agreed to be managed.
Evidence that the conflict was managed as intended (for example recording the points during the meeting when individuals left or returned to the meeting).

Management of interests – Common situations

The following sections set out the principles and rules to be adopted by staff in common situations, and what information should be declared.

Gifts

This policy prohibits the offer or receipt of gifts, hospitality, payment or expenses whenever these could affect or be perceived to affect the outcome of business transactions and are not reasonable and bona fide expenditure. All staff should be aware that gifts and hospitality can be used as a subterfuge for bribery and, if this is suspected it should be reported immediately to the Local Counter Fraud Specialist.

A gift means any item of cash or goods, or any service, which is provided for personal benefit, free of charge, or at less than its commercial value.

Staff should not accept gifts that may affect, or be seen to affect, their professional judgement. If you are in any doubt as to whether to accept a gift, it is better to politely decline the offer.

Gifts from suppliers or contractors:

Gifts from suppliers or contractors doing business (or likely to do business) with the organisation should always be declined, whatever their value.
Low cost branded promotional aids such as pens or post-it notes may, however, be accepted where they are under the value of £6 in total and need not be declared. The £6 value has been selected with reference to existing industry guidance issued by the Association of the British Pharmaceutical Industry (ABPI)

Gifts from other sources (e.g. patients, families, service users):

Staff must not ask for any gifts.
Personal gifts of cash or cash equivalents (e.g. vouchers, tokens, offers of remuneration to attend meetings whilst in a capacity working for or representing the ICB) to individuals must always be declined whatever their value and whatever their source, and the offer which has been declined must be declared and recorded on the register.
Gifts valued at over £50 should be treated with caution and only be accepted on behalf of the ICB and not in a personal capacity. These should be declared by staff, providing a clear reason as to why it was considered permissible to accept the gift, alongside the actual or estimated value, to the ICB Governance Lead in order to agree how these should be used, for example, donated to a local charity.
Modest gifts accepted under a value of £50 do not need to be declared.

A common-sense approach should be applied to the valuing of gifts (using an actual amount, if known, or an estimate that a reasonable person would make as to its value).

Multiple gifts from the same source over a twelve-month period should be treated in the same way as single gifts over £50 where the cumulative value exceeds £50.

The acceptance or rejection of gifts should be declared on the form provided at Appendix C, which summarises the above rules, and submitted to the Governance Team.

Hospitality (including Meals, Refreshments, Travel and Accommodation)

Delivery of services across the NHS relies on working with a wide range of partners (including industry and academia) in different places and, sometimes, outside of ‘traditional’ working hours. As a result, staff will sometimes appropriately receive hospitality. Staff receiving hospitality should always be prepared to justify why it has been accepted and be mindful that even hospitality of a small value may give rise to perceptions of impropriety and might influence behaviour.

The total value of hospitality provided by any specific company to the ICB must not exceed £1,000 in one financial year.

Staff should not ask for or accept hospitality that may affect, or be seen to affect, their professional judgement.

Hospitality must only be accepted when there is a legitimate business reason, and it is proportionate to the nature and purpose of the event.

Caution must be exercised when hospitality is offered by actual or potential suppliers or contractors. This can be accepted, and must be declared, if modest and reasonable, but caution should be exercised if a contract re-tender is imminent. Advice should be sought from the Governance Lead and prior approval by the relevant Executive Director must be obtained.

Meals and refreshments:

Under a value of £25 – may be accepted and need not be declared.
Of a value between £25 and £75 – may be accepted and must be declared. The £75 value has been selected with reference to existing industry guidance issued by the ABPI.
Over a value of £75 – should be refused unless (in exceptional circumstances) prior approval by the relevant Director is given. A clear reason should be recorded on the organisation’s register(s) of interest as to why it was permissible to accept.
In the case of modest hospitality offered by pharmaceutical companies, the ICB requires clarity on what products are to be promoted. If the product(s) has been rejected for use in the Essex ICB area, the offer should be declined. Advice should be sought from the Pharmacy and Medicines Optimisation Team where appropriate.
A common-sense approach should be applied to the valuing of meals and refreshments (using an actual amount, if known, or an estimate that a reasonable person would make as to its value).

Travel and accommodation:

Modest offers to pay some or all travel and accommodation costs related to attendance at events may be accepted and must be declared.
Offers which go beyond modest or are of a type that the organisation itself might not usually offer should be politely refused. However, there might be some limited and exceptional circumstances where accepting these types of hospitality may be contemplated. In these circumstances, prior approval by the relevant Director is required and must be declared.
A clear reason should be recorded on the organisation’s register(s) of interest as to why it was permissible to accept travel and accommodation of this type. A non-exhaustive list of examples includes:
hospitality of a value above £75 per attendee.
offers of business class or first-class travel and accommodation (including domestic travel).
offers of foreign travel and accommodation.

The acceptance or rejection of hospitality should be declared on the form provided at Appendix C, which summarises the above rules, and submitted to the Governance Team.

With regard to the provision of hospitality by the Integrated Care Board, The Code of Conduct: Code of Accountability in the NHS advises that the use of NHS monies for hospitality and entertainment, including hospitality at conferences or seminars, should be carefully considered. Expenditure on these items should be capable of justification, as reasonable in the light of general practice in the public sector. The provision of hospitality or entertainment is open to challenge by auditors and ill-considered actions can damage public perception and respect for the NHS.

Outside employment

The NHS relies on staff with good skills, broad knowledge and diverse experience. Many staff bring expertise from sectors outside the NHS, such as industry, business, education, government and beyond. The involvement of staff in these outside roles alongside their NHS role can therefore be of benefit, but the existence of these should be well known so that conflicts can be either managed or avoided.

Outside employment means employment and other engagements, outside of formal ICB employment arrangements. This can include employment within another NHS organisation, directorships, non-executive roles, self-employment, consultancy work, charitable trustee roles, political roles and roles within not-for-profit organisations, paid advisory positions and paid honorariums which relate to bodies likely to do business with the ICB.

The ICB requires employees, committee members, contractors and others engaged under a contract with the ICB to declare if they are employed or engaged in any employment, business, consultancy, or voluntary role in addition to their work with the ICB.

Staff must declare any existing outside employment/engagement on their appointment and any new outside employment/engagement when it arises.

Where a risk of conflict of interest arises, the general management actions outlined in this policy should be considered and applied to mitigate risks.

Where contracts of employment or terms and conditions of engagement permit, staff will be required to seek prior approval from the ICB to engage in outside employment.

The ICB may also have legitimate reasons within employment law for knowing about outside employment of staff, even when this does not give rise to risk of a conflict. Nothing within this policy prevents such enquiries being made.

The ICB requires that individuals obtain prior written permission from a director to engage in outside employment. The ICB reserves the right to implement appropriate arrangements to manage any conflict(s) and to refuse permission for outside employment where it believes a conflict will arise which cannot be effectively managed.

In particular, it is unacceptable for pharmacy advisers or other advisers, employees or consultants to the ICB on matters of procurement to themselves to be in receipt of payments from the pharmaceutical or devices sector.

Trading on official premises is prohibited, whether for personal gain or on behalf of others. Canvassing/advertising by, or on behalf of, outside bodies or firms (including non-ICB interests of staff or their relatives) is also prohibited. Official ICB email accounts and documentation such as letter headed paper / logos should not be used for private enterprise and may constitute an offence of fraud.

The ICB will implement arrangements to facilitate the declaration of outside employment by new staff upon their appointment by completion of the Declaration of Interest form at Appendix B. This process will be managed by the ICB’s Human Resources and Governance Teams with relevant outside employment interests being recorded within the register of interest.

Shareholdings and other ownership issues

Holding shares or other ownership interests can be a common way for staff to invest their personal time and money to seek a return on investment. However, conflicts of interest can arise when staff personally benefit from this investment because of their role with the ICB. For instance, if they are involved in their organisation’s procurement of products or services which are offered by a company they have shares in then this could give rise to a conflict of interest.

Staff should declare, as a minimum, any shareholdings and other ownership interests in any publicly listed, private or not-for-profit company, business, partnership or consultancy which is doing, or might be reasonably expected to do, business with the ICB or member organisations of the wider Integrated Care Partnership.

Where shareholdings or other ownership interests are declared and give rise to risk of conflicts of interest then the general management actions outlined in this policy should be considered and applied to mitigate risks.

There is no need to declare shares or securities held in collective investment or pension funds or units of authorised unit trusts.

Shareholdings and other ownership issues should be declared on the form provided at Appendix B and will be recorded within the register of interests.

Patents

The development and holding of patents and other intellectual property rights allows individuals to protect something that they create, preventing unauthorised use of products or the copying of protected ideas. However, conflicts of interest can arise when staff that hold patents and other intellectual property rights are involved in decision making and procurement.

Staff should declare patents and other intellectual property rights they hold (either individually, or by virtue of their association with a commercial or other organisation), including where applications to protect have started or are ongoing, which are, or might be reasonably expected to be, related to items to be procured or used by the organisation.

Staff should seek prior permission from the ICB before entering into any agreement with bodies regarding product development, research, work on pathways etc, where this impacts on the ICB’s time, or uses its equipment, resources or intellectual property.

Where holding of patents and other intellectual property rights give rise to a conflict of interest then the general management actions outlined in this policy should be considered and applied to mitigate risks.

Relevant patents must be declared on the form provided at Appendix B and submitted to the Corporate Governance Team for recording within the register of interests.

Loyalty interests

Conflicts of interest can arise when decision making is influenced through association with colleagues or organisations out of loyalty to the relationship they have, rather than through an objective process.

Loyalty interests should be declared by staff involved in decision making where they:

Hold 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.
Sit 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 the ICB does business with an organisation in which close family members and relatives, close friends and associates, and business partners have decision making responsibilities.

Where holding loyalty interests gives rise to a conflict of interest then the general management actions outlined in this guidance should be considered and applied to mitigate risks

Loyalty interests must be declared on the form provided at Appendix B and submitted to the Governance Team for recording within the register of interests.

Donations

A donation is a charitable financial payment, which can be in the form of direct cash payment or through the application of a will or similar directive. Charitable giving and other donations are often used to support the provision of health and care services. As a major public sector employer the NHS holds formal and informal partnerships with national and local charities. Staff will, in their private lives, undertake voluntary work or fundraising activities for charity. A supportive environment across the NHS and charitable sector should be promoted. However, conflicts of interest can arise.

Donations made by suppliers or bodies seeking to do business with the ICB should be treated with caution and not routinely accepted. In exceptional circumstances they may be accepted but should always be declared. A clear reason should be recorded as to why it was deemed acceptable, alongside the actual or estimated value.

Staff should not actively solicit charitable donations unless this is a prescribed or expected part of their duties for the ICB or is being pursued on behalf of the ICB’s own registered charity (if any) or other charitable body and is not for their own personal gain.

Staff must obtain permission from the ICB if in their professional role they intend to undertake fundraising activities on behalf of a pre-approved charitable campaign for a charity other than the organisation’s own.

Donations, when received, should be made to a specific charitable fund (never to an individual) and a receipt should be issued.

Staff wishing to make a donation to a charitable fund in lieu of receiving a professional fee may do so, subject to ensuring that they take personal responsibility for ensuring that any tax liabilities related to such donations are properly discharged and accounted for.

The ICB will maintain records in line with the above principles and rules and relevant obligations under charity law.

The ICB will not recommend alternative organisations or charities as recipients of the donation where it has deemed the offer as something the ICB will not accept. A clear reason should be recorded as to why it was deemed acceptable, alongside the actual or estimated value.

Commercial sponsorship

This section should be read in conjunction with section 6.28, Joint working with the pharmaceutical industry.

ICB staff, the Board and committee members may be offered commercial sponsorship for events such as courses, conferences, post/project funding, meetings and publications in connection with the activities which they carry out for or on behalf of the ICB. All such offers (whether accepted or declined) must be declared so that they can be included on the ICB’s register of gifts, hospitality and commercial sponsorship, and the Head of Governance should provide advice on whether or not it would be appropriate to accept any such offers. If such offers are reasonably justifiable then they may be accepted, with the written approval of a director or the Governance Lead.

Acceptance of commercial sponsorship should not in any way compromise commissioning decisions of the ICB or be dependent on the purchase or supply of goods or services. Any payment that is received for speaking at events in organisation time should be paid to the NHS organisation.

Sponsors should not have any influence over the content of an event, meeting, seminar, publication or training event. The ICB should not endorse individual companies or their products. It should be made clear that the fact of sponsorship does not mean that the ICB endorses a company’s products or services. Sponsorship of ICB events by appropriate external bodies should only be approved if a reasonable person would conclude that the event will result in clear benefit for the ICB and the NHS.

During dealings with sponsors there must be no breach of patient or individual confidentiality or data.

No information should be supplied to a company for their commercial gain and information which is not in the public domain should not normally be supplied unless there is a clear benefit to the NHS or patients.

At the ICB’s discretion, sponsors or their representatives may attend or take part in the event, but they should not have a dominant influence over the content or the main purpose of the event. The involvement of a sponsor in an event should always be clearly identified in the interest of transparency.

For further information on what to do if offered sponsorship, see Appendix C.

Clinical private practice

Service delivery in the NHS is done by a mix of public, private and not-for-profit organisations. The expertise of clinicians in the NHS is in high demand across all sectors and the NHS relies on the flexibility that the public, private and not-for-profit sectors can provide. It is therefore not uncommon for clinical staff to provide NHS funded care and undertake private practice work either for an external company, or through a corporate vehicle established by themselves.

Existing provisions in contractual arrangements make allowances for this to happen and professional conduct rules apply. However, these arrangements do create the possibility for conflicts of interest arising. Therefore, these provisions are designed to ensure the existence of private practice is known so that potential conflicts of interest can be managed. These provisions around declarations of activities are equivalent to what is asked of all staff in the section on outside employment.

Clinical staff should declare all private practice on appointment, and/or any new private practice when it arises including:

Where they practise (name of private facility).
What they practise (specialty, major procedures).
When they practise (identified sessions/time commitment).
Hospital consultants are already required to provide their employer with this information by virtue of paragraph 3, schedule. 9 of Terms and conditions – consultants (England)
Action taken to mitigate against a conflict, including details of any approvals given to depart from the terms of this policy.

Clinical staff should (unless existing contractual provisions require otherwise or unless emergency treatment for private patients is needed):

Seek prior approval of the ICB before taking up private practice.
Ensure that, where there would otherwise be a conflict or potential conflict of interest, NHS commitments take precedence over private work. (these provisions already apply to hospital consultants by virtue of paragraphs 5 and 20, schedule 9 of the Terms and conditions – consultants (England).
Not accept direct or indirect financial incentives from private providers other than those allowed by Competition and Markets Authority guidelines: Non-Divestment_Order_amended.pdf

Hospital Consultants should not initiate discussions about providing their Private Professional Services for NHS patients, nor should they ask other staff to initiate such discussions on their behalf (these provisions already apply to hospital consultants by virtue of paragraphs 5 and 20, schedule 9 of the Terms and conditions – consultants (England)).

Staff should declare involvement with clinical private practice to the ICB by using the form at Appendix B which should be submitted to the Governance Team for inclusion on the relevant register.

Strategic decision making groups

In common with other NHS bodies the ICB 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.
Selection of medicines, equipment, and devices.

The interests of those who are involved in these groups should be well known (as highlighted on registers of interests provided to each meeting) so that they can be managed effectively. For this organisation these groups include:

The ICB Board
The ICB’s main Committees as set out in its Constitution
Essex Medicines Optimisation Committee

These groups should adopt the following principles:

Chairs should consider any known interests of members in advance and begin each meeting by asking for declaration of relevant material interests.
Members should take personal responsibility for declaring material interests at the beginning of each meeting and as they arise.
Any new interests identified should be added to the appropriate register.
The vice chair (or other non-conflicted member) should chair all or part of the meeting if the chair has an interest that might prejudice their judgement.
Terms of reference for such groups should refer to the organisation’s policy and procedures for managing conflicts of interest and should set out any specific requirements which apply to the group.

If a member has an actual or potential interest the chair should consider the following approaches and ensure that the justification and reason for the chosen action is documented in the minutes of the meeting and (where appropriate) other records:

Requiring the member to not attend the meeting.
Excluding the member from receiving meeting papers relating to their interest.
Excluding the member from all or part of the relevant discussion and/or decision and where necessary, securing technical or local expertise from an alternative unconflicted source.
Including a conflicted person in the discussion and decision where there is a clear benefit to them being included in both – however, including the conflicted person in the actual decision should be done after careful consideration of the risk and with proper mitigation in place. The rationale for inclusion should also be properly documented and included in minutes.
Noting the nature and extent of the interest but judging it appropriate to allow the member to remain and participate.
Removing the member from the group or process altogether.
Consider using a sub-committee to remove potential conflict from core committee membership.

The default response should not always be to exclude members with interests, as this may have a detrimental effect on the quality of the decision being made. Good judgement is required to ensure proportionate management of risk.

The Chair of a meeting has ultimate decision-making responsibility regarding how conflicts of interest are managed.

Procurement

Procurement should be managed in an open and transparent manner, compliant with procurement and other relevant law, to ensure there is no discrimination against or in favour of any provider. Procurement processes should be conducted in a manner that does not constitute anti-competitive behaviour which is against the interest of patients and the public.

Those involved in procurement exercises for and on behalf of the organisation should keep records that show a clear audit trail of how conflicts of interest have been identified and managed as part of procurement processes. At every stage of procurement steps should be taken to identify and manage conflicts of interest to ensure and to protect the integrity of the process.

In relation to the Provider Selection Regime, where decisions are being taken as part of a formal competitive procurement of services, any individual who is associated with an organisation that has a vested interest in the procurement should recuse themselves from the process.

The procedure for managing conflicts of interest during procurements is set out in the ICB’s Procurement and Contracting Policy. Further information about the PSR, including about the management of conflicts of interest, can be found within the PSR statutory guidance.

Contract management

Any contract monitoring meeting needs to consider conflicts of interest as part of the process. The chair of a contract management meeting should: invite declarations of interests; record any declared interests in the minutes of the meeting; and manage any conflicts appropriately and in line with this policy. This equally applies where a contract is held jointly with another organisation or with other ICBs under lead commissioner arrangements.

The individuals involved in the monitoring of a contract should not have any direct or indirect financial, professional, or personal interest in the incumbent provider or in any other provider that could prevent them, or be perceived to prevent them, from carrying out their role in an impartial, fair and transparent manner.

The ICB will consider any potential conflicts of interest when circulating any contract or performance information/reports on providers and manage the risks appropriately.

Joint working with the pharmaceutical industry

This section should be read in conjunction with section 6.20, Commercial sponsorship.

The Department of Health (DH) and the Association for British Pharmaceutical Industry (ABPI) seek to encourage collaborative working for the benefit of the local healthcare economy and ultimately the patient.

Pharmaceutical companies that are members of the ABPI are required to comply with the ABPI Code of Practice for the Pharmaceutical Industry 2016 which regulates the promotion of prescription medicines and certain other non-promotional activities.

The ABPI guidance seeks to provide a framework and greater clarity for pharmaceutical companies about various aspects of Joint Working and Sponsorship.

This section of the policy is intended to:

Ensure transparency for all our stakeholders on our approach to joint working with the pharmaceutical industry.

Promote ethical working relationships between the pharmaceutical industry and the NHS and should be used in conjunction with the DH/ABPI document “Moving beyond sponsorship: Interactive toolkit for joint working between the NHS and the pharmaceutical industry”

Joint working can be defined as “situations where, for the benefit of patients, one or more pharmaceutical companies and the NHS pool skills, experience and/or resources for the joint development and implementation of patient centred projects and share a commitment to successful delivery”.The key requirements from this definition are:

Any joint working project must be focused on benefits to patients
There must be a “pooling” of resources between the pharmaceutical company or companies and the NHS organisation(s) involved. Each party must, therefore, make a significant contribution to the Joint Working project to avoid the arrangement being construed as merely a gift, benefit in kind, donation or some other non- promotional/commercial practice. Resources may come in various forms, including people, expertise, equipment, communication channels, information technology and finance.

Other principles to be applied to any instances of joint working and sponsorship are:

All joint working and sponsorship will support projects that address local and national priorities and will maintain the freedom of clinicians to prescribe the most clinically appropriate and effective treatment for individual patients.
Joint working and sponsorship will be conducted in an ethical, open and transparent manner.
Joint working will take place at a corporate (organisational) level, and not with individual healthcare professionals or NHS administrative staff.
Joint working contracts will be negotiated on fair and reasonable terms, in line with NHS values.
Confidentiality of information received in the course of the joint working arrangement will be respected and never used outside the scope of the project. All patient identifiers will be removed from data to preserve and respect patient confidentiality in line with the Data Protection Act 2018.
In the interests of transparency, the overall arrangements for joint working and sponsorship must be made public via the ICB website.
Joint working and sponsorship is based on mutual trust and respect. Pharmaceutical companies must comply with the ABPI Code at all times. All NHS employed staff should comply with NHS, the ICB and relevant professional body codes of conduct at all times.
Clinical and prescribing policies or guidelines must be based upon principles of evidence-based medicine and cost effectiveness. They will be consistent with national recommendations including the National Institute for Health and Clinical Excellence (NICE), expert bodies such as the Royal College of General Practitioners (RCGP) and local guidance.
The Pharmaceutical industry should not have undue influence.
Sponsorship must not provide personal benefit.

Any Joint Working/Sponsorship must ensure that all arrangements are neutral, free from preference regarding the use of the company’s product over other more clinically appropriate or cost-effective products or services. In addition, arrangements must be in keeping with local guidelines and formularies.

The ICB will act in a transparent, objective manner, never endorsing any individual company or product through such agreements.

Where joint working is being contemplated, full consideration of the proposal must be given before any agreement is made. Advice should be sought from the Pharmacy and Medicines Optimisation Team and the Governance Lead. Legal advice may also be necessary.

There must be a specific agreement for each joint working project which contains information on:

The name of the joint working project, the parties to the agreement, the date and the term of the agreement.
The expected benefits for patients, the NHS and the pharmaceutical company.
How the success of the project will be measured, when and by whom. A set of baseline measurements must be established at the outset of the project to track and measure the success of the project aims, particularly patient outcomes. For longer term projects (>1 year) patient outcomes should be analysed at least every six months as a minimum to ensure that anticipated patient benefits are being delivered.
An outline of the financial arrangements.
The roles and responsibilities of the ICB and the pharmaceutical company. All aspects of input from the company should be included such as training, support for service redesign, business planning, data analysis etc.
The agreement should specify criteria that result in high certainty that both parties can meet their commitments. For example, both parties should be able to demonstrate that they have the capability, resource or track record to deliver on the commitments they are making.
The planned publication of any data or outcomes.
Procedures for dealing with Freedom of Information Act requests.
If a pharmaceutical company enters into a joint working agreement on the basis that its product is already included in an appropriate place on the local formulary, a clear reference to this should be included in the joint working agreement so that all the parties are clear as to what has been agreed.
The agreement should include contingency arrangements to cover possible unforeseen circumstances such as changes to summaries of product characteristics and updated clinical guidance. Agreements should include a dispute resolution clause and disengagement/exit criteria including an acknowledgement by the parties that the project might need to be amended or stopped if a breach of the ABPI Code is ruled.

Approval must be obtained from the Commissioning Committee or relevant sub-group before the project proceeds. This will allow a full evaluation of the joint working agreement including governance issues and the overall impact of the joint working to be assessed in relation to healthcare priorities.

Joint Working offers of any kind from pharmaceutical companies must be declared and registered whether refused or accepted and be available for public scrutiny on request.

The ICB will encourage competitor companies to collaborate on any such ventures. If several companies are able to provide the same arrangements they should all – or at least a selection – be approached to ascertain their willingness to undertake joint working. If willing to do so, they could then share a joint working arrangement.

Any joint working arrangements will be reported to the Audit, Risk and Compliance Committee.

A primary care rebate scheme (PCRS) is an agreement between an ICB and a pharmaceutical company that provides an economic benefit to the commissioner and, in theory, may increase the volume sales of a company’s product. These are different to national patient access schemes which are negotiated nationally by the Department of Health to enable patient access for very high-cost drugs that have clear clinical benefits. PCRS could be seen to undermine national pricing agreements between the Department of Health and Industry.

The ICB believes that the pharmaceutical industry should supply medicines to the NHS using transparent pricing mechanisms, wherever possible.
The ICB does accept rebates from pharmaceutical companies. The decision as to whether to accept a rebate is made by the Pharmacy & Medicines Optimisation Team based on the PrescQIPP operating model.

Prevention of fraud and bribery

The ICB is committed to preventing fraud and bribery and encourages staff with concerns or reasonably held suspicion about potentially fraudulent activity or practice to report these immediately to the ICB’s Local Counter Fraud Specialist (LCFS), whose contact details can be obtained via the ICB’s intranet. Suspicions may also be reported to the Executive Director of Finance and Commercial, or to the ICB Chair or ICB Chief Executive Officer where it would not be appropriate to report to the Executive Director of Finance and Commercial.

Suspicions of fraud can also be reported directly and confidentially to the NHS Fraud and Corruption Reporting Line on 0800 028 4060 or via https://cfa.nhs.uk/reportfraud.

Identifying and reporting breaches

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. For the purposes of this policy these situations are referred to as ‘breaches’.

Staff who are aware about actual breaches of this policy, or who are concerned that there has been, or might be, a breach, should report these concerns to one of the officers listed below, whose contact details are set out on Appendix D:

The ICB’s Local Counter Fraud Specialist (who is the first point of contact for any genuine suspicions or concerns regarding fraud or bribery, as per the ICB’s Counter Fraud, Bribery and Corruption Policy).
National Fraud and Corruption Line 0300 123 2040
The Executive Director of Corporate Services
The ICB Governance Lead.
The Conflicts of Interest Guardian.
The Executive Director of Finance and Commercial.

To ensure that interests are effectively managed staff are encouraged to speak up about actual or suspected breaches. Every individual has a responsibility to do this. For further information about how concerns should be raised please refer to the ICB’s Freedom to Speak Up (Whistleblowing) Policy.

The ICB will investigate each reported breach according to its own specific facts and merits and give relevant parties the opportunity to explain and clarify any relevant circumstances.

Following investigation, the ICB will:

Decide if there has been or is potential for a breach and, if so, what the severity of the breach is.
Assess whether further action is required in response – this is likely to involve any staff member involved and their line manager, as a minimum.
Consider who else inside and outside the organisation should be made aware
Take appropriate action as set out in the next section.

Taking action in response to breaches

Action taken in response to breaches of this policy will be in accordance with the disciplinary procedures of the organisation and could involve organisational leads for staff support (e.g. Human Resources), fraud (e.g. Local Counter Fraud Specialist), members of the management or executive teams and auditors.

Any potential breach of the conflicts of interest elements of this policy will be investigated and actual breaches published on the ICB website. This includes the treatment of service contracts where a breach of conflicts of interest was identified.

Potential breaches highlighted during the course of ICB business, reported to the Conflicts of Interest Guardian or identified in any other way, will be documented by the Executive Director of Corporate Services and investigated.

Each breach needs to be investigated and judged on its own merits, and this should start with those involved having the opportunity to explain and clarify any relevant circumstances.

A conflict of interest panel will be assembled by the Executive Director of Corporate Services. The panel will be chaired by a non-executive board member and a minimum of two other non-executive board members will be members of the panel.

All documented evidence will be compiled by the Executive Director of Corporate Services or their representative and circulated to panel members at least five working days prior to the panel meeting.

There is an expectation that the individual being investigated will respond to questions and provide evidence sought in a timely manner to reduce possible delay.

The ICB recognises that receiving requests as part of the investigative process could be distressing for the individuals, and therefore HR will be approached to provide or sign-post relevant support.

Witnesses and the individual being investigated may be invited to the meeting if appropriate.

The panel meeting will be minuted by the Executive Director of Corporate Services, or their representative. and minutes will be kept on file for a minimum of six years.

The role of the panel is to assess whether an actual breach has occurred and to decide on a course of action to reflect the consequences of that breach.

Legal or other appropriate advice may be sought prior to imposing sanctions which could have serious consequences for those involved, Appendix 5 outlines the ‘Potential Sanctions’ (as per NHS England Managing Conflicts of Interest Guidance 2024).

Breaches could require action in one or more of the following ways:

Clarification or strengthening of existing policy, process and procedures.
Consideration as to whether HR/employment law/contractual action should be taken against staff or others.
Consideration being given to escalation to external parties. This might include referral of matters to external auditors, NHS Counter Fraud Authority, the Police, statutory health, or social care bodies (such as NHS England, Care Quality Commission, Local Government Association, and/or health professional regulatory bodies.

Inappropriate or ineffective management of interests can have serious implications for the organisation and staff. There will be occasions where it is necessary to consider the imposition of sanctions for breaches in accordance with the ICB’s Disciplinary Policy.

Sanctions should not be considered until the circumstances surrounding breaches have been properly investigated. However, if such investigations establish wrong-doing or fault then the ICB can and will consider the range of possible sanctions that are available, in a manner which is proportionate to the breach. This includes:

Employment law action against staff, which might include
Informal action (such as reprimand or signposting to training and/or guidance).
Formal disciplinary action (such as formal warning, the requirement for additional training, re-arrangement of duties, re-deployment, demotion, or dismissal).
Reporting incidents to the external parties/regulators described above for them to consider what further investigations or sanctions might be.
Where the individual is not a direct employee, review of their appointment to the role that has given rise to the conflict.
Civil/contractual action, such as exercise of remedies or sanctions against the body or staff which caused the breach, e.g. a claim for misfeasance in public office.
Criminal sanctions such as investigation and prosecution under fraud, bribery, and corruption legislation, i.e. the Fraud Act 2006 and Bribery Act 2010.

Statutorily regulated healthcare professionals who work for, or are engaged by, the ICB are under professional duties imposed by their relevant regulator to act appropriately with regard to conflicts of interest. The ICB will report statutorily regulated healthcare professionals to their regulator if they believe that they have acted improperly, so that these concerns can be investigated. Statutorily regulated healthcare professionals should be made aware that the consequences for inappropriate action could include fitness to practise proceedings being brought against them, and that they could, if appropriate, be struck off by their professional regulator as a result. and

Transparency concerning breaches

Anonymised reports on breaches, the impact of these, and actions taken will be considered by the Audit, Risk and Compliance Committee and any other relevant committee/group.

To aid transparency the ICB will consider whether anonymised information on breaches and action taken in response should be prepared and published on its website.

Monitoring compliance

Compliance with this policy will be monitored in the following ways:

As part of the routine monitoring undertaken by the ICB Governance Lead.
Monitoring completion rates of mandatory training relating to the management of conflicts of interest and taking action where necessary to improve completion rates, which must be a minimum of 90% compliance as of 31 March each year.
Annual Audit of arrangements to manage conflicts of interest undertaken by the ICB’s auditors, including an annual review by Counter Fraud as part of requirement 12 Government Functional Standards.
The Audit, Risk and Compliance Committee will monitor compliance with this policy and the declaration of interest process via reporting as identified in the committee’s workplan.
Anonymised reporting on breaches and significant issues relating to the management of conflicts of interest to the Audit, Risk and Compliance Committee or other relevant committee.
Identification and monitoring of any associated risks.
By submission of any returns required by NHSE/I in relation to the management of conflicts of interest, which will be signed-off by the Conflicts of Interest Guardian.

Implementation and staff training

Induction training must be provided to all employees, Board members and members of ICB committees and sub-committees on the management of conflicts of interest. This is to ensure staff and others within the ICB understand what conflicts are and how to manage them effectively.

Induction training will cover the following:

What is a conflict of interest?
Why is conflict of interest management important?
What are the responsibilities of the organisation you work for in relation to conflicts of interest?
What should you do if you have a conflict of interest relating to your role, the work you do or the organisation you work for (who to tell, where it should be recorded, what actions you may need to take and what implications it may have for your role).
How conflicts of interest can be managed.
What to do if you have concerns that a conflict of interest is not being declared or managed appropriately.
What are the potential implications of a breach of the ICB’s rules and policies for managing conflicts of interest?
Other areas monitored: Gifts, Hospitality, Commercial Sponsorship, Pharmaceutical Industry, Joint Working.

All ICB staff will be required to undertake training deemed to be mandatory by NHSE/I or the ICB on the management of conflicts of interest available via the Electronic Staff Record (ESR). As a minimum, all staff will be required to complete Module 1, with Modules 2 and 3 to be completed by senior staff/Board members as identified on the ICB’s mandatory training matrix.

The ICB will also implement arrangements to ensure that non-ICB staff who are members of the Board or its committees have undergone suitable training on the management of conflicts of interests.

Those staff with responsibility for decision-making or providing advice and support regarding the management of conflicts of interest (including the ICB Governance Lead, other governance staff and the Conflicts of Interest Guardian) will be required to undertake appropriate additional training relating to the management of conflicts of interest.

Additional training needs may be identified, for example, where a breach has occurred or to provide a member of staff with additional knowledge to undertake their role effectively.

Completion of mandatory training will be monitored and action taken to address completion rates where necessary.

Arrangements for review

This policy will be reviewed annually. An earlier review will be carried out in the event of any relevant changes in legislation, national or local policy/guidance, organisational change or other circumstances which mean the policy needs to be reviewed.

Views and input from relevant stakeholders will be sought when the policy is reviewed, including those of the ICB’s Local Counter Fraud Specialist and procurement advisers.

If only minor changes are required, the sponsoring committee (Audit, Risk and Compliance Committee) has authority to make these changes without referral to the ICB Board. If significant or substantial changes are required, the policy will need to be ratified by the relevant committee before final approval by the ICB Board.

Associated policies, guidance and documents

Associated guidance and legislation

Managing Conflicts of Interest in the NHS, 17 September 2024
Managing Conflicts of Interest Mandatory Training Modules 1, 2 and 3, available via Electronic Staff Record.
Guidance on integrated care board constitutions and governance, 26 July 2024
www.england.nhs.uk/ourwork/coi
Freedom of Information Act 2000
ABPI: The Code of Practice for the Pharmaceutical Industry (2021)
ABHI Code of Ethical Business Practice https://www.abhi.org.uk/membership/code-of-ethical-business-practice/
NHS Code of Conduct and Accountability (July 2004)
The Provider Selection Regime (PSR) Statutory Guidance
Economic Crime and Corporate Transparency Act (ECCT).
NHS Fit and Proper Person Test
General Medical Council: Identifying and Managing Conflicts of Interest
Transparency and doctors with competing interests – guidance from the British Medical Association February 2025

Associated ICB Policies

MSEICB 003 Procurement and Contracting Policy
MSEICB 023 Freedom to Speak Up Policy
MSEICB 026 Counter-Fraud, Bribery and Corruption Policy
MSEICB 045 Disciplinary Policy

References

This policy is primarily based on:

Managing Conflicts of Interest in the NHS, 17 September 2024

Equality impact assessment (EIA)

The EIA (Appendix A) identified no equality issues with this policy.

Appendix A – Equality impact assessment

Initial information

Name of policy: Conflicts of Interest Policy
Directorate/Service: Corporate Services
Version number (if relevant): 1.0
Assessor’s Name and Job Title: Sara O’Connor, Senior Manager Corporate Services
Date: 6 February 2026

Outcomes

This policy is designed to enable the ICB and its staff and partner organisations to effectively manage conflicts of interest in situations where conflicts might arise (e.g. during decision making/procurement processes, offers of gifts and hospitality, commercial sponsorship and outside employment).

Evidence

The ICB monitors the composition of its workforce under the nine protected equality characteristics and reports on this annually. This information helps the ICB to assess the potential impact of its policies upon staff.

The policy is based on the NHS England/Improvement Policy template for managing conflicts. The Staff Engagement Group have been consulted on the policy and their feedback will be considered before the policy is finalised.

Analysis of impact on equality

The Public Sector Equality Duty requires us to eliminate discrimination, advance equality of opportunity and foster good relations with protected groups. Consider how this policy / service will achieve these aims.

N.B. In some cases it is legal to treat people differently (objective justification).

Positive outcome – the policy/service eliminates discrimination, advances equality of opportunity and fosters good relations with protected groups
Negative outcome – protected group(s) could be disadvantaged or discriminated against
Neutral outcome – there is no effect currently on protected groups

Please tick to show if outcome is likely to be positive, negative or neutral. Consider direct and indirect discrimination, harassment and victimisation.

Protected group	Neutral outcome	Reason(s) for outcome
Age	X	The onus is on every individual to declare their interests. However, there is a risk that staff from protected groups may be reluctant to use the policy to raise concerns because of fear of discrimination, harassment or victimisation. However it is considered that this risk will be minimised by the assurances given in the associated Freedom to Speak Up Policy and reference within the Conflicts of Interest Policy that employees will not be penalised for raising honest concerns and by the regular monitoring of reported cases.
Disability(Physical and Mental/Learning)	X	As above.
Religion or belief	X	As above
Sex (Gender)	X	As above
Sexual Orientation	X	As above
Transgender/Gender Reassignment	X	As above
Race and ethnicity	X	As above
Pregnancy and maternity (including breastfeeding mothers)	X	As above
Marriage or Civil Partnership	X	As above

Monitoring outcomes

Monitoring is an ongoing process to check outcomes. It is different from a formal review which takes place at pre-agreed intervals.

An anonymised summary of breaches will be provided to the Audit Committee. If pertinent, the summary will identify where an individual’s protected group status was relevant to the circumstances investigated and identify any lessons learned in this respect.

Review

Annually

N/A

Appendix B -Declaration of interest form Appendix C – Gifts and Hospitality Declaration Form

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