Appendices

Being fair tool: Supporting staff following a patient safety incident

By treating staff fairly, the NHS can foster a culture of openness, equity and learning where staff feel confident speaking up when things go wrong. Supporting staff to be open about mistakes allows valuable lessons to be learnt and prevents errors from being repeated.

However, in rare circumstances a staff member’s response to learning may raise concerns about an individual’s conduct or fitness to practise. It is in these specific circumstances that being fair decision-making tool can help you decide what next steps to take.

Where criminal activity is suspected to have contributed to death, or serious or life-changing harm, you should refer the healthcare incident to the police and be guided by the memorandum of understanding between healthcare organisations and regulatory, investigatory and prosecutorial bodies.

Before using the tool, consider the following questions (Sidney Dekker, 2022):

• Who is hurt? (for example, staff, patients, family, public)
• What do they need? (for example, wellbeing support, information on what happened)
• Whose responsibility is it to meet that need? (for example, occupational health, patient safety team)

The NHSE ‘Being Fair’ tool can be accessed at this link: Being Fair Tool

Chief Executive Officer (CEO)

Legal Basis/Regulatory: NHS Act 2006 (as amended by the Health and Care Act 2022)

Summary of Duties

• The overall leader and accountable officer of the NHS organization.
• Responsible for day-to-day management and delivery of services and strategy.
• Ensures the organisation meets its statutory duties, for quality standards and financial targets.

Chief Nurse

Legal/Regulatory Basis: NHS Act 2006 (as amended by the Health and Care Act 2022)

Summary of Duties

• Responsible for professional leadership and accountability for Nursing, Midwifery and Allied Health Professionals.
• Board accountability for safeguarding ensuring there are effective systems to safeguard both patients and staff.
• Statutory responsibility for Infection Prevention and Control.
• Joint responsibility with the Medical Director for quality and patient safety.
• Executive professional lead for Maternity and Children’s Services.
• CQC-registered manager for the organisation.

Medical Director

Legal/Regulatory Basis: NHS Act 2006 (as amended by the Health and Care Act 2022)

Summary of Duties

• Responsible Officer to General Medical Council.
• Executive responsible for the Mental Health Act.
• Executive responsible for Medicines Management.
• Responsible for Medical Education, professional development and workforce, and for pharmacists, dentists, physicians, anaesthetics associates, and health care scientists.
• Joint responsibility for quality and safety.
• Responsible for Trust Mortality including the Medical Examiner Service.
• Executive lead for Research and Innovation.
• Regulated as per all doctors by the GMC Good Medical Practice via appraisal and revalidation. The responsible officer is the Higher-Level Responsible Officer at NHSE Midlands.

Chief Financial Officer

Legal/Regulatory Basis: NHS Act 2006 (as amended by the Health and Care Act 2022)

Summary of Duties

• Statutory duties relating to accountability and probity of sound financial management.
• Professionally qualified and head of profession in the organisation.
• Treasurer activities.
• Stewardship of public sector resources.
• Executive responsible for Counter Fraud.
• Executive responsible for Estates and Facilities, including Fire Safety.

Other Key Roles (linked to Accountability) 

1. Chief Operating Officer (COO)

Legal/Regulatory Basis: Code of governance for NHS provider trusts.
Purpose: Responsible for the day-to-day operational management of the Trust, ensuring efficient and effective delivery of clinical service.

• Required in the NHS: No. 

2. Chief People Officer (CPO)

Legal/Regulatory Basis: No statutory requirement.
Purpose: Responsible for leading workforce strategy, organisational culture, staff wellbeing, and ensuring compliance with HR policies and employment law.

• Required in the NHS: No. 

3. Company Secretary/Director of Corporate Governance (DoCG)

Legal/Regulatory Basis: NHS Trust are expected to comply with the NHS Foundation Trust Code of Governance, which outlines the need for a Company Secretary.
Purpose: The Company Secretary ensures strong governance by supporting the Board, maintaining legal and regulatory compliance, and enabling transparent, accountable decision-making across the organisation.

• Required in the NHS: Yes. 

4. Chief Digital and Transformation Officer (CDTO)

Legal/Regulatory Basis: Code of governance for NHS provider trusts 
Purpose: Oversees the NHS's operational IT provision, cyber security, and digital strategy.  

• Required in the NHS: No, not mandated for every NHS Trust. 

5. Caldicott Guardian

Legal/Regulatory Basis: Caldicott Principles (DHSC) guidance
Purpose: Protects patient confidentiality and oversees the use of personal information.

• Required In the NHS: Yes.  

6. Senior Information Risk Owner (SIRO)

Legal/Regulatory Basis: Required by Department of Health and Social Care.
Purpose: Oversees information risk, data protection, and security.

• Required In the NHS: Yes.

7. Responsible Officer (Medical Revalidation) 

Legal/Regulatory Basis: The Medical Profession (Responsible Officers) Regulations 2010.

Purpose: Ensures that doctors are fit to practise through regular revalidation.

• Required In the NHS: Yes.

8. Freedom to Speak Up Guardian

Legal/Regulatory Basis: NHS England policy 
Purpose: Supports staff to raise concerns safely and confidentially.

• Required In the NHS: Yes.

9. Safeguarding Leads (Children and Adults) 

Legal Basis: Children Act 2004, Care Act 2014 and NHS England Safeguarding Policy.
Purpose: Ensures the protection of vulnerable children and adults.

• Required In the NHS: Yes.

10. Fire Safety Officer / Responsible Person

Legal/Regulatory Basis: Regulatory Reform (Fire Safety) Order 2005.
Purpose: Ensures fire safety compliance across NHS buildings.

• Required In the NHS: Yes.

11. Health and Safety Officer

Legal/Regulatory Basis: Health and Safety at Work etc Act 1974 and Health and Safety at Work Regulations 1999.
Purpose: Ensures health and safety of staff, patients, and visitors.

• Required In the NHS: Yes.

12. Data Protection Officer (DPO)

Legal/Regulatory Basis: UK GDPR and Data Protection Act 2018.
Purpose: Ownership of the organisation’s information risk policy

• Required In the NHS: Yes.

13. Counter Fraud Officer (external official)

Legal/Regulatory Basis: The Counter Fraud Officer, is an employee of the NHS Counter Fraud Authority (NHSCFA) and is accountable to the Department of Health and Social Care.

Purpose: Identifying, investigating, and preventing fraud, bribery, and corruption within the NHS

• Required in the NHS: Yes

14.       Accountable Emergency Officer

Legal/Regulatory Basis: National Health Service Act 2006 – Section 252A

Purpose: This section establishes the statutory duty for NHS organisations to ensure emergency preparedness, resilience, and response (EPRR). It mandates that a board-level director is designated as the AEO with executive authority to ensure compliance and provide assurance to the Board.

• Required in the NHS: Yes

1.    Allied Health Professionals

Collectively, allied health professionals (AHPs) are the third largest clinical workforce in the NHS: 185,000 allied health professionals (AHPs) in 14 professions are working across the spectrum of health and care, education (including early years), academia, research, criminal justice system, voluntary and private sectors. 

NUH employs 1800 AHPs across nine professions in all services and clinical care groups. They include:

• Operating Department Practitioners (ODPs)
• Diagnostic radiographers 
• Therapeutic radiographers
• Orthoptists
• Orthotists  
• Occupational therapists
• Physiotherapists
• Speech and language therapists
• Dietitian

2.    Healthcare Science (HCS)

They are involved in 80% of all clinical decisions in the NHS and in developing some of the most amazing clinical and technological advancements. There are over 50 different specialisms in healthcare science. Our HCS provide the scientific backbone of the NHS, and they perform a wide range of roles associated with the prevention, diagnosis & treatment of disease.  

NUH employ more than 1,000 HCS staff working across the clinical care groups in 25 specialisms. Broadly they fall into the following themes: 

• Life sciences
• Clinical bioinformatics
• Physical sciences and biomechanical engineering
• Physiological sciences

3.    Pharmacy 

Pharmacy professionals are made up of two separate professions, both registered with the General Pharmaceutical Council.

Pharmacists: 

Pharmacists ensure prescribed medicines are clinically appropriate, legally supplied, and of high quality. They advise healthcare professionals on safe and effective use and supply of medicines.

Pharmacy Technicians:

Pharmacy Technicians manage the supply of medicines, manufacture medicines, take an active role in providing patients with guidance on taking medicines and assist Pharmacists with advisory services.  

Current Position (August 2025)

• NHS managers operate under employment contracts and are subject to:
  • Organisational policies and codes of conduct.
  • Fit and Proper Person Test (FPPT) under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, applies to directors and those performing equivalent roles.
  • Performance appraisal systems, internal disciplinary procedures, and professional standards frameworks (e.g. NHS Leadership Competency Framework).
• No independent register currently exists for NHS managers, although some managers are voluntarily registered with professional bodies (e.g. Chartered Management Institute, Institute of Healthcare Management).

Future Direction 

In November 2024, the Department of Health and Social Care launched a consultation titled Leading the NHS: Proposals to Regulate NHS Managers, which closed in February 2025. The consultation received over 4,900 responses, with 92% of participants supporting the regulation of NHS managers. This feedback has informed the government's commitment to introduce statutory measures, including a barring system for senior NHS leaders found guilty of serious misconduct. The Health and Care Professions Council (HCPC) is expected to oversee this barring scheme.

The government's proposals encompass:

1. Statutory Barring Mechanism: Establishing a list of individuals barred from holding senior NHS roles due to serious misconduct.
2. Professional Duty of Candour: Holding NHS managers legally accountable for responding to patient safety concerns. The Guardian
3. Professional Standards and Code of Practice: Developing a national framework outlining expected competencies and conduct for NHS managers. GOV.UK
4. Support and Development: Establishing a new College of Executive and Clinical Leadership to provide training and professional development for NHS managers.

1. Department of Health and Social Care

Aims to improve the health and wellbeing of the nation, supporting people to live more independent, healthier lives for longer. This involves leading the development of health and social care policy, overseeing the NHS and social care systems, and ensuring access to high-quality, sustainable services.  

2. NHS England (schedule to be abolished; functions to be absorbed by the Department of Health and Social Care)

3. Integrated Care Board (ICB)

Future remit, focus on strategic commissioning. 

4. Care Quality Commission (CQC)

Regulates and inspects health and social care services in England.
Ensures services provide safe, effective, compassionate, and high-quality care.

5. National Institute for Health and Care Excellence (NICE)

Provides evidence-based guidance and advice to improve health and social care.
Sets quality standards for healthcare.

6. NHS Resolution

Handles negligence claims and disputes involving the NHS

Statutory Regulators for Healthcare Professionals

Statutory regulation refers to professions that must be registered with a professional regulatory body by law. Employers must check that healthcare professionals are registered with an appropriate regulated body by law and are fit and licensed to practice in their chosen profession before they start work. They should also ensure that professionals continue to maintain registration and fitness to practice for the full duration of employment with them.

 

There are nine statutory professional regulatory bodies across the health and care sectors. Each regulator maintains a register of individuals who meet the required standards set for the specific profession. Including standards of education, training, professional skills, behaviour and health.

Each regulator has its own systems to enable you to check their registers and have detailed processes of how to alert them if you have concerns about an individual's fitness to practise. You can find these on the websites below.

The Professional Regulators

• Nursing and Midwifery Council (NMC) regulates nurses, midwives and nursing associates.
• General Medical Council (GMC) regulates doctors.
• General Chiropractic Council (GCC) regulates the chiropractic profession.
• General Dental Council (GDC) regulates dental professionals. This includes dentists, dental nurses, dental technicians, clinical dental technicians, dental hygienists, dental therapists and orthodontic therapists.
• General Optical Council (GOC) regulates the optical professions.
• General Osteopathic Council (GOsC) regulates the practice of osteopathy.
• General Pharmaceutical Council (GPhC) regulates pharmacists, pharmacy technicians and pharmacy premises in Great Britain.
• Health and Care Professions Council (HCPC) regulates 15 health and care professions: arts therapists, biomedical scientists, chiropodists/podiatrists, clinical scientists, dietitians, hearing aid dispensers, occupational therapists, operating department practitioners, orthoptists, paramedics, physiotherapists, practitioner psychologists, prosthetists/orthotists, radiographers and speech and language therapists.
• Pharmaceutical Society of Northern Ireland (PSNI) is the regulatory and professional body for pharmacists in Northern Ireland.

Annual results will be published each year on NUH’s website and feature at our Annual Public Meeting.

To show our dedication to transparency and ongoing improvement, we have set up key monitoring metrics. These metrics act as a standard for our accountability, helping us to measure our performance and ensure we meet our statutory duties and national standards.

This list is not exhaustive and will be further developed through ongoing engagement with our Patient Experience Group, Staff Networks, and external stakeholders.

 

Trust and Openness Performance Measures (End of Financial Year)

Area	Measure / Description	Target	Result (End of Financial Year)
Statutory Duty of Candour	Percentage of written disclosures completed within 10 working days. The statutory Duty of Candour (Regulation 20, Health and Social Care Act 2008) requires NHS organisations to inform patients (or families/carers) when a notifiable safety incident occurs. This includes providing a clear explanation, offering an apology, and sharing details of investigations and actions taken to prevent recurrence.	≥ 80%
Complaints responded to within 40 days	Percentage of complaints responded to within 40 days. This is an internal performance benchmark used by NHS organisations, including NUH, to improve the timeliness of complaint handling.	≥ 85%
Patient Experience Score	Measure of overall patient experience.	To be developed

Outcomes – Performance against National Access Standards (End of Financial Year)

Measure	Description	Target	Results (End of Financial Year)
18-week Referral to Treatment	Under the NHS Constitution, patients in England have the right to start consultant-led treatment within a maximum of 18 weeks from referral by a GP or other healthcare professional. This metric shows how closely we comply with that guideline.	≥ 70.8%
4-hour wait (A&E performance)	Tracks whether patients attending A&E are admitted, transferred, or discharged within four hours of arrival. This reflects compliance with NHS Constitution guidelines.	≥ 78%
Cancer 62-day pathway	Measures whether patients begin cancer treatment within 62 days of referral, in line with NHS Constitution standards.	≥ 75%
Summary Hospital-Level Mortality Indicator (SHMI)	The SHMI compares the actual number of patient deaths following hospitalisation with the number expected, based on national averages and adjusted for factors such as age, diagnosis, and pre-existing conditions. It includes deaths in hospital or within 30 days of discharge, providing a broad measure of mortality associated with hospital care. A value of 1.00 means deaths are as expected; above 1.00 indicates more deaths than expected, below 1.00 indicates fewer.	Within expected limits

Finance – End of Financial Year Performance

Measure	Description	Target	Results (End of Financial Year)
Statutory duty to break even	Under paragraph 2(1) of Schedule 5 to the National Health Service Act 2006, NHS trusts must ensure that income is sufficient to meet expenditure. This is known as the break-even duty. It means NHS trusts are legally required to manage finances so that, over time, they do not spend more than they receive. The duty is measured over a rolling five-year period and monitored by NHS England and the Department of Health and Social Care.	Break even

Governance – End of Financial Year Performance

Measure	Description	Target	Results (End of Financial Year)
Trust Board papers publication	Trust Board papers must be published on the NUH website at least 3 working days before each scheduled Board meeting. NHS Trusts are legally required to publish board meeting agendas and papers in advance, as set out in their Standing Orders.	100%
Head of Internal Audit Opinion	This metric provides an assessment of the effectiveness of NUH’s governance, risk management, and internal control systems.	Significant Assurance
NHS Trust Performance League Table Position	In November 2024, the Secretary of State announced that NHS England would assess NHS trusts against a range of performance criteria and publish the results. This allows NHS England to determine the level of support individual trusts need to improve.	Publish
CQC Well-Led inspection summary	The Care Quality Commission (CQC) assesses the “Well-Led” domain, including leadership, governance, culture, and the ability to deliver high-quality care. Inspection reports and ratings are published, and a summary is shared on our website to demonstrate performance, outline actions taken in response to concerns, and support transparency and accountability.	Publish

Communications – End of Financial Year Performance

Measure	Description	Target	Results (End of Financial Year)
Public Accountability Statement of Intent	The Public Accountability Statement of Intent and associated key metrics and performance will be shared with patients and stakeholders and published on the Trust website following the Trust Board meeting in July 2026.	30 July 2026

Give feedback or raise concerns

You can raise concerns or make complaints about Nottingham University Hospitals (NUH) through the Patient Advice and Liaison Service (PALS), the Friends and Family Test (FFT), or the formal complaints process. Feedback helps NUH improve services and address issues.

More information is available on the PALS section and Friends and Family Test page on the NUH website.

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1. Friends and Family Test (FFT)

The Friends and Family Test (FFT) is a national scheme that allows patients to share feedback about the quality of care they receive.

You can give feedback via:

• The NUH website
• iPads available on wards and some clinical areas
• FFT feedback cards with freepost envelopes
• QR codes or links in discharge letters and patient information leaflets

2. Patient Advice and Liaison Service (PALS)

PALS is a free, confidential service offering advice, support and information if you are experiencing difficulties with our services.

PALS can:

• Help you raise concerns or explain how to make a formal complaint
• Provide information about POhWER (NHS complaints advocacy service)
• Signpost you to other organisations and support services

Contact PALS

Telephone: 0800 183 0204 or 0115 924 9924 ext. 85412 / 82301

Email: nuhnt.pals@nhs.net

In person

• Queen’s Medical Centre (QMC): B Floor, Monday–Friday 9am–4pm (excluding bank holidays)
• Nottingham City Hospital: South Corridor, Junction S6, Monday–Friday 9am–4pm (excluding bank holidays)

Post

NUH NHS Trust, c/o PALS, Freepost NEA 14614, Nottingham NG7 1BR

3. Attending public meetings

NUH Board meetings are open to the public. Papers and minutes are published in advance, and public questions may be submitted before meetings.

NUH also holds an Annual Public Meeting (APM) each year, usually in early autumn, to share updates and achievements.

Contact

Telephone: 0115 969 1169 ext. 71001

Email: nuhnt.corporatemeetings@nhs.net

Post: Chief Executive’s Office, Trust Headquarters, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB

4. Patient and Public Involvement (PPI)

NUH involves patients and the public in shaping services through surveys, forums and consultation events.

Telephone: 0115 969 1169

5. Maternity and Neonatal Voices Partnership (MNVP)

The Nottingham and Nottinghamshire Maternity and Neonatal Voices Partnership brings together families, staff and organisations to improve maternity care.

Email: nnccg.nottsmvp@nhs.net

Also available on social media.

6. POhWER (independent advocacy)

POhWER is an independent charity providing advocacy and support for people needing help to raise concerns.

• Telephone: 0300 456 2370
• Email: pohwer@pohwer.net
• Text: Send “pohwer” with your name and number to 81025
• Post: PO Box 17943, Birmingham, B9 9PB
• Relay UK supported for hearing or speech difficulties

7. Freedom of Information (FOI)

NUH is committed to transparency and publishes information wherever possible.

If information is not available, you can submit a request or contact the Data Protection Office.

Contact Data Protection Office

• Telephone: 0115 924 9924 ext. 86838
• Email: nuhnt.dutyin@nhs.net
• Post: Data Protection Office, NUH NHS Trust, QMC Campus, Derby Road, Nottingham NG7 2UH

8. Parliamentary and Health Service Ombudsman (PHSO)

The PHSO independently investigates complaints about the NHS where issues have not been resolved locally.

Telephone: 0345 015 4033

9. Contact your local MP

You can contact your MP if:

• You feel you have been treated unfairly
• You want to raise issues affecting your local community

MPs can make enquiries on your behalf or refer cases to the PHSO.

• Telephone: 0800 112 4272 or 020 7219 4272
• Email: hcenquiries@parliament.uk
• Post: House of Commons Enquiry Service, London SW1A 0AA

10. Care Quality Commission (CQC)

You can share feedback with the CQC about your experience of care. This is not a formal complaint process.

The CQC uses feedback to help improve health and care services across England.

• Telephone: 03000 616161
• SignLive: Sign language interpreter service via app
• TextRelay: 18001 03000 616161