Freedom to speak up policy

This policy describes the approach the trust takes to create a culture and a framework within which staff feel free to speak up, confident that they will be listened to and supported, and their concerns will be acted upon. 

Our freedom to speak up reports can be found in our Board Papers.

Executive summary

It is vitally important that all staff feel able to voice any concerns they have at work. Raising concerns helps the trust to keep improving its services for patients, and the working environment for staff.

The trust understands that staff may feel worried about raising a concern. The aim of this policy is to make it as easy as possible for staff to raise concerns, to support them when they do, and to reassure them of the steps the trust will take to make sure their concerns are listened to, taken seriously, and addressed.

People who blow the whistle have special protection under the law. This policy describes how whistle-blowers will be supported.


Speaking up about any concern you have at work is important. In fact, it is vital as it will help the Trust to keep improving its services for all patients and the working environment for our staff.

Staff may feel worried about raising a concern and this is understandable, however, please do not be disconcerted. In accordance with the Trust’s Duty of Candour, the Board and Senior Managers are committed to an open and honest culture. There is a commitment to look into what you report and you will always have access to the support you need.


This policy is available to all staff, as well as agency and temporary workers, contractors and volunteers. The term ‘staff’ is used throughout the policy to include all these staff groups.

Staff can raise a concern about anything they think is harming the service we deliver. Some examples of this are included in section 4.3 below.

If the concern is a personal complaint that affects only the individual, rather than a concern about something that affects others, then staff may wish to raise the issue through the trust’s grievance policy or bullying and harassment policy. If the concern is about fraud it should be raised with the trust’s local counter-fraud specialist. Incidents, errors and near misses should be reported through the trust’s incident reporting system.


This “standard integrated policy” was one of a number of recommendations of the review by Sir Robert Francis into whistleblowing in the NHS; aimed at improving the experience of whistleblowing in the NHS. This benchmark policy has been adopted by all NHS organisations in England as a minimum standard to help to normalise the raising of concerns for the benefit of all patients. The principles ascribed within the Trust’s former Whistleblowing Policy have been fully integrated into this policy


What you can expect from the Trust

 We will:

  • Treat you with respect at all times and thank you for raising your concern.
  • Treat your concern confidentially unless otherwise agreed.
  • Understand that you may be upset, nervous or worried about raising your concern Advise you if the concern raised should be referred to a different process e.g. fraud investigation, grievance etc.
  • Ask you what your expectations are in terms of a successful outcome from the concerns you have raised.
  • Draw up terms of reference for an investigation based on the information you provide.
  • Appoint an appropriate investigator who has not been involved in the concern, or in any other processes with you and inform you who this will be.
  • Advise that you will need to be part of the investigation along with other staff in the area i.e. interviewed by the investigator.
  • Provide indicative timeframes for the investigation.
  • Discuss and agree how you will be kept informed of progress.
  • Share the recommendations/outcomes of the investigation report once complete.
  • Identify sources of support that are available for you.
  • Not tolerate harassment or bullying of whistle blowers as a result of raising concerns.
  • Ensure that if other processes run parallel to the investigation e.g. disciplinary issues as a result of poor care, these will be investigated and managed separately from the concern raised.
  • Share lessons learnt in the relevant department and across the Trust as appropriate.


What the Trust will expect of you

You will:

  • Act appropriately, professionally and proportionally.
  • Be prepared to provide the information and facts you possess and answer questions to the best of your ability (not vague assertions).
  • Express yourself as calmly as possible (not exaggerated, not defamatory).
  • Reasonably believe it is a matter of public interest (not a personal matter).
  • Raise the matter according to this policy.
  • Understand that the investigation will find out the facts independently.
  • Accept that the outcome, whilst reasonable and fair, may not be the outcome you wanted.
  • Provide feedback to the Freedom to Speak Up Guardian on your experience of raising a concern.
  • Speak up again in future if the need arises.


 What concerns can be raised?

You can raise a concern about risk, malpractice or wrongdoing you think is harming the service the Trust delivers and/or commissions.

A few examples of this might include, but are by no means restricted to:

  • Unsafe patient care.
  • Unsafe working conditions.
  • Inadequate induction or training for staff.
  • Lack of, or poor, response to a reported patient safety incident.
  • Suspicions of fraud (which can be reported to our local counter-fraud team at The NHS Counter Fraud Authority at or on 0800 028 40 60.
  • A bullying culture (across a team or organisation rather than individual instances of bullying)
  • A criminal offence has been committed, is being committed or is likely to be committed.
  • That the environment has been, is being or is likely to be damaged.

If you are a healthcare professional, you may have a professional duty to report a concern. If in doubt, please raise it. Do not wait for proof; the Trust would like you to raise the matter while it is still a concern. It does not matter if you have been mistaken, as long as you are genuinely worried. Please note that this policy is not for people with concerns about their employment that affect only them. That type of concern is better suited to our Grievance and Collective Disputes Policy.


Feeling safe to raise your concern

If you raise a genuine concern, under this policy, you will not be at risk of losing your job or suffering any form of reprisal as a result. The Trust will not tolerate the harassment or victimisation of anyone raising a concern or any attempt to bully you into not raising any such concern. Such behaviour is a breach of our values as an organisation and, if upheld following investigation, could result in disciplinary action.

Provided you are acting honestly, it does not matter if you are mistaken or if there is an innocent explanation for your concerns.



In the spirit of openness, the Trust would wish you to feel comfortable raising your concern, but appreciates that you may want to raise it confidentially. This means thatwhilst you are willing for your identity to be known to the person you report your concernto, you do not want anyone else to know your identity. Therefore, your identity will be kept confidential, if that is what you want, unless required to disclose it by law, for example, by the police or if it is required to be disclosed for the purposes of subsequent disciplinary action. If this becomes the case, staff would be informed accordingly.

You can choose to raise your concern anonymously, but that may make it more difficult for the Trust to investigate thoroughly and give you feedback on the outcome.


Who can raise concerns?

Anyone who works (or has worked) in the NHS or, for an independent organisation that provides NHS services, can raise concerns. This includes agency workers, temporary workers, students, doctors in training, volunteers and governors.


Who should I raise my concerns with?

In many circumstances, the easiest manner to get your concern resolved will be to raise it formally or informally with your line manager (or lead clinician or tutor). In the case of governors, please contact the Membership Office. Where you do not think it is appropriate to do this, you can use any of the options set out below in the first instance.

If raising it with your line manager (or lead clinician or tutor) does not resolve matters, or you do not feel able to raise it with them, you can contact: One of the Trust’s Freedom to Speak Up Guardians.

This is an important role identified in the Freedom to Speak Up Review, to act as an independent and impartial source of advice to staff at any stage of raising a concern, with access to anyone in the organisation, including the Chief Executive, or if necessary, outside the organisation.

The Moorfields Freedom to Speak Up Guardians are:

  • Dr Ali Abbas
  • Farhana Sultana-Miah
  • Carmel Brookes
  • Ian Tombleson (Lead Guardian)

If you still remain concerned after this, you can contact: The Trust’s identified Non-Executive Director with responsibility for raising concerns via the company secretary at   020 7253 3411

All these people have been trained in receiving concerns and will give you information about where you can go for more support. If for any reason you do not feel comfortable raising your concern internally, you can raise concerns with external bodies.


Advice and support

 Details on the local support available to you can be found at:

  • Department of Health
  • Local Staff Side Representatives
  • Care Quality Commission (CQC)
  • Fraud and Fiscal Irregularities:
    • Counter Fraud Office
    • Serious Fraud Office
    • Inland Revenue
    • Custom and Excise
  • Health and Safety Dangers – Health and Safety Executive
  • Charities Commission
  • Occupational Pensions Regulatory Authority
  • Information Commissioner
  • NHS Improvement
  • NHS England

You can also contact the Whistleblowing Helpline for the NHS and Social Care (0800 072 4725 or at, your professional body or trade union representative.


How should I raise my concern?

You can raise your concern with any of the people listed above in person, by telephone or in writing, including email. You can also contact your local Trade Union Representative. Whichever route you choose, please be ready to explain as fully as you can theinformation and circumstances that gave rise to your concern. Please refer to the Standard Operating Procedure for Freedom to Speak Up.


Raising your concern with an outside body

Alternatively, you can raise your concern outside the organisation with:

  • NHS Improvement for concerns about:
    • How NHS trusts and foundation trusts are being run.
    • Other providers with an NHS provider licence.
    • NHS procurement, choice and competition on the national tariff.
  • Care Quality Commission for quality and safety concerns.
  • NHS England for concerns about:
    • Primary medical services (general practice).
    • Primary dental services.
    • Primary ophthalmic services.
    • Local pharmaceutical service.
  • Health Education England for education and training in the NHS.
  • NHS Protect for concerns about fraud and corruption.


Making a ‘protected disclosure’

There are very specific criteria that need to be met for an individual to be covered by whistleblowing law when they raise a concern (to be able to claim the protection that accompanies it). There is also  a defined list of “prescribed persons”, similar to the list of outside bodies listed above, to whom you can make a protected disclosure. To help you consider whether you might meet these criteria, please seek independent advice from the Whistleblowing Helpline for the NHS and Social Care (0800 072 4725 or at, Public Concern at Work (0207 404 6609 or email or contact a legal representative.


National Freedom to Speak Up Guardian

 A National Guardian, Dr Henrietta Hughes, has been appointed, and can independently review how staff have been treated having raised concerns where NHS trusts and foundation trusts may have failed to follow good practice, working with some of the bodies listed above to take action where needed.


Counselling and support for staff

Although every attempt will be made to ensure that staff are supported throughout this process, the Trust does recognise that staff may feel the need to receive counselling. To this end, the Trust has a contract with Validium, which is a self-referralservice for

counselling and support. This organisation is open 24 hours x 365 days a year and can be telephoned on 0800 3584858. The only information following any contact that will be submitted to the Trust will be the number of contacts and the Directorate. The Trustwishes that staff be assured that this is a confidential service and no detailed information, including names, is shared.

You can also access online support through vClub at



Awareness of the policy and process is done via induction. In addition, “Raising Concerns” and “Responding to Concerns” are educational tools developed by Health Education England to support healthcare professionals at all levels, ensuring they feel empowered to both raise and respond to concerns. The films look at three scenarios that highlight broad lessons to be applied elsewhere. As well as stressing the importance of raising and responding to concerns, the films explain what to do and signpost to further information. 


Malicious complaints

Staff will not be punished for raising genuine concerns. However, if during aninvestigation it is found that an individual raises a complaint maliciously then we will consider whether it is serious enough to address through the trust’s disciplinary policy.


Explanation of terms used

Fraud is unlawfully obtaining Trust property or attempting to do so.

Harassment is conduct that is unreciprocated or unwanted and which affects the dignity of men and women at work. It includes behaviour that is unreasonable, offensive or hostile causing discomfort, distress, or exclusion, or constituting an infringement of the rights of any employee.

PIDA is the Public Disclosure Act (1998).

Whistleblowing is when a worker reports suspected wrongdoing at work. Officially this is called ‘making a disclosure in the public interest’.



This section lists those within the trust who have specific responsibilities within the policy (separately to the Freedom to Speak Up Guardians and non-executive director with responsibility for speak up as detailed above). Any of these can be contacted by staff who wish to raise a concern.

The chief executive is responsible for appointing the FTSU Guardian and is ultimately accountable for ensuring that FTSU arrangements meet the needs of the workers intheir trust. The chief executive and chair are responsible for ensuring the annual report

contains information about FTSU and that the trust is engaged with both theregional Guardian network and the National Guardian’s Office.

Both the chief executive and chair are key sources of advice and support for their FTSU Guardian and meet with them regularly.

Line managers have prime responsibility for addressing staff concerns, and General Managers are nominated managers to receive concerns. If possible, an individual should raise their concerns first with their line manager. This may be done by speaking to him or her, or by putting it in writing. An individual may ask a Contact Officer, an HR adviser or their trade union representative to accompany them to a meeting, or to help putting their concerns into writing. If an individual feels unable to raise the matter with their immediate manager, for whatever reason, they should if possible raise the matter with their senior manager, clinical director, or the director responsible for their department. If staff feel unable to raise concerns through line management, there are a range of other people they can contact.

The trust’s medical director has professional responsibility for all the trust’s doctors, and the director of nursing and allied health professions has similar responsibility for nurses and AHPs. Either of these individuals can be contacted about any matter concerning these groups of staff.

The trust’s Risk Management Team can be contacted about any matter to do with riskor safety.

Staff may contact any executive or non-executive director, or the company secretary for a confidential discussion. If the concern raised relates to the chair or chief executive then staff should contact the Senior Independent Director via the company secretary.

Our local counter fraud specialist or chief financial officer should be contacted in the case of fraud.

Contact colleagues are staff members who have volunteered to be a point of contact for staff who have concerns but are not sure whether or where to raise them. They are specially trained, and can act to raise concerns on behalf of staff if necessary. More information can be found about Contact Colleagues on the intranet.


Stakeholder engagement and communication

This policy has been developed in consultation between HR and Learning and Development, Corporate Governance and Marketing and Communications, and members of the trust’s Joint Consultative Committee.


Approval and ratification

The director of quality & safety and company secretary approve this policy. Ratification is by the Management Executive.


Dissemination and implementation

This policy will be widely communicated via the intranet, weekly bulletin and posters. Refresh communications will be issued from time to time and at every substantiverevision.


Review and revision arrangements

This policy will be reviewed by the policy owner/author every three years. It will also be reviewed if reporting to the Trust Board indicate areas for improvement, and if the relevant legislation changes.


Document control and archiving

The current and approved version of this document can be found on the Trust’s intranet site. Should this not be the case, please contact the Quality and Compliance team.


Monitoring compliance with this policy

The company secretary will provide an annual report to the Trust Board on activityarising from the operation of this policy.

The report will include information on:

  • How often the policy has been activated formally.
  • Types of issues raised.
  • How many allegations were upheld, how many were rejected wholly or partly and for what reasons.
  • Resources used in implementing the policy.
  • Achievements against the set timetable to respond (usually four weeks).
  • Improvements of services resulting from the process.

It will also cover issues raised through other channels, including relevant other incidents which were not referred to as whistle-blowing but which could or should have been dealt with as a whistle-blowing issue.



Annex A: Raising concerns in the NHS

Source: Sir Robert Francis QC (2015) Freedom to Speak Up. an independentreport into creating an open and honest reporting culture in the NHS.


Freedom to speak up raising concerns infographic

Policy applicability to Trust sites

This document applies to all premises occupied by Trust staff/activities.

Moorfields in the UAE will adhere to their own local policies and procedures andTrust- wide documents will not apply, unless explicitly stated otherwise.


Equality impact assessment

The equality impact assessment is used to ensure we do not inadvertently discriminate as a service provider or as an employer.

To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval.

If you have identified a potential discriminatory impact of this procedural document, please refer it to the director of quality and safety, or the human resources department, together with any suggestions as to the action required to avoid/reduce this impact.

For advice in respect of answering the above questions, please contact the director of quality and safety.


Checklist for the review and approval of documents

To be completed (electronically) and attached to any document which guides practice when submitted to the appropriate committee for approval or ratification.

Title of the document:                   Freedom to Speak Up/Whistleblowing Policy

Policy (document) Author:          Company secretary

Policy (document) Owner:           Director of quality & safety


The Public Interest Disclosure Act 1998 


The Public Interest Disclosure Act 1998 promotes accountability in the public, private and voluntary sectors by encouraging members of staff not to ignore malpractice in the workplace. It provides rights and remedies, which protect staff from recriminations and reprisals by employers as a result of raising concerns or allegations over malpractice. The remedies include protection from dismissal or demotion. The aim of all this is to ensure that organisations address the message rather than the messenger and resist the temptation to cover up malpractice.



The law applies to people at work raising genuine concerns about crime, illegality, miscarriage of justice, danger to health and safety or the environment and any cover up thereof. Since the Act became law, concerns raised within the NHS as malpractice have included abuse of patients, financial impropriety and personal use of the services of hospital contractors.


Individuals Covered

The Act applies to most employed people, including NHS employees, trainees, agency staff and home care workers. The usual employment law restrictions on minimum qualifying periods and age in seeking redress against an employer under the Employment Rights Act 1996 do not apply over rights and remedies under the PublicInterest Disclosure Act. The Act however does not apply to self-employed people, volunteers, the intelligence services, the armed forces or the police.


Internal Disclosures

A public interest disclosure of alleged malpractice should primarily be made to the employer. This must satisfy three tests; the disclosure must be in good faith, in the reasonable belief that it tends to show impropriety and in accordance with the employer’s whistleblowing policy.


Regulatory Disclosures

The Act makes special provision for disclosures to statutory regulators approved by Parliament to act thereon. They include the Audit Commission, the Charity Commission, the Data Protection Authority and the Health and Safety Executive. Professional regulatory bodies are specifically excluded. Disclosures to approved authorities will be protected where the whistleblower meets the test for internal disclosures and in addition honestly and reasonably believes that the information and any allegation therein are substantially true.


Wider Disclosures

Wider disclosures (for example to MPs, the police, professional regulators and the media) are protected, if in addition to the test related to statutory regulators, such disclosures are reasonable in all the circumstances and are not made for personal gain.

There are two parts to the reasonableness test. Firstly, the whistleblower must reasonably believe that he or she would be victimised and secondly, the concernmust have been

raised privately with the employer of a statutory regulator. Provided these provisions are met and an Employment Tribunal is satisfied the disclosure was reasonable under all circumstances, the whistleblower will be protected.


Full Protection

Where a whistle blower suffers detriment at work, such as victimisation or dismissal, in breach of the Act, he or she may pursue a claim to an Employment Tribunal. Any claim must be within three months of suffering detriment or dismissal. The Tribunal has the power to fine an employer and award compensation to the whistleblower. Where an employer dismisses a whistleblower, he or she may apply to the Tribunal for immediate reinstatement provided the application is made within seven days of the date oftermination of employment.


Gagging Clauses

Gagging clauses in employment contracts and severance agreements are void where they conflict with the legal protection given to employees under the Act.

Public Concern at Work can provide further guidance and information.