Our policies

On 1 February 2021, Royal Brompton and Harefield hospitals became part of Guy’s and St Thomas’ NHS Foundation Trust. Royal Brompton & Harefield NHS Foundation Trust is no longer an independent Trust and, in light of this, we will be reviewing the policies on this page over the coming months.

All directors, governors and staff must be impartial, honest and above suspicion in the conduct of their duties. Specifically, they are not permitted to further their personal interests, whether paid or voluntary, in the course of their duties at the Trust. 

All directors, governors and staff have personal responsibility for their conduct and are expected to anticipate and declare any potential conflict of interest including in relation to gifts, hospitality and sponsorship. These are recorded on the Trust’s Register of InterestRegister of Interests - Board of Directors and Register of Interests - Staff.  

Read our conflict of interest policy (PDF, 444KB).

NHS Improvement certification

At its meeting on 18 June 2020, the Trust Board approved the certifications for publication on the Trust website

Agreement of the statements contained in these certificates is a requirement of the NHS Provider Licence which is issued to the Foundation Trust by NHS Improvement (the Regulator).

Self Certification G6 and CoS7 (PDF, 184KB)

Training of Governors May 2019 (PDF, 175KB)

We need to plan for, and respond to, a wide range of incidents and emergencies that could affect health or patient care at any of our sites. These could be anything from extreme weather conditions to an outbreak of an infectious disease or a major transport accident. The Civil Contingencies Act (2004) requires NHS organisations to show that they can deal with such incidents while maintaining services.

This work is referred to in the health community as emergency preparedness, resilience and response (EPRR) and we work closely with other hospitals and emergency services in planning for and managing all types of incidents.

All organisations are required to undertake annual assurance and the Trust received a compliance rating of Substantial for 2017/18.

We have a dedicated emergency preparedness officer but every member of staff plays a vital role in ensuring a professional NHS response to an incident

If you need further information, please email Catherine Philpott, emergency planning and business continuity manager: c.philpott@rbht.nhs.uk


Useful external links

Public Health England

London Resilience 

Local authority: RBKC 

Local authority: Hillingdon

Met Office

Report online material promoting terrorism or extremism

Equality Act 2010

The Equality Act 2010 became law on 1 October 2010 replacing the previous anti-discrimination legislation with a single Act that simplifies and strengthens the law.     

Trust equality objectives - April 2016 to April 2020

The Trust will focus on the following objectives between April 2016 and April 2020:   

  • The Trust will tailor its responses to all patients’ needs in care, treatment and communication to ensure that the standards of the Equality Act 2010 are met at all times.           
  • In particular, the Trust will seek to tailor these in respect of older patients, seeking improvements in outcomes for this cohort.
  • The Trust will continue to promote equal opportunities in personal, professional and career development for all its staff by making quality educational, developmental and leadership programmes available to all.
  • The Trust will continue to promote equal opportunities in recruitment, ensuring that all candidates have an equal chance of appointment based solely on their own merits.

Gender pay gap reporting

Gender pay gap report 2021

Royal Brompton & Harefield NHS Foundation Trust gender pay gap report - 31 March 2021 (PDF, 806KB)

Gender pay gap report 2020

Royal Brompton & Harefield NHS Foundation Trust gender pay gap report - 31 March 2020 (PDF, 959KB)

Gender pay gap report 2019

Royal Brompton & Harefield NHS Foundation Trust gender pay gap report - 31 March 2019 (PDF, 386KB)

Gender pay gap report 2018

Royal Brompton & Harefield NHS Foundation Trust gender pay gap report - 31 March 2018 (PDF, 452KB)

Trust equality and diversity information

Workforce Disability Equality Standard (WDES) 2020

Workforce Disability Equality Standard 2020 (PDF, 826KB)

Workforce Disability Equality Standard (WDES) 2019

Workforce Disability Equality Standard 2019 (PDF, 158KB)

Workforce Race Equality Standard (WRES) 2020

Workforce Race Equality Standard 2020, (PDF, 617KB) 

Workforce Race Equality Standard (WRES) 2019

Workforce Race Equality Standard (WRES) 2019 (PDF, 150KB)

Workforce Race Equality Standard (WRES) 2018

Workforce Race Equality Standard  - 1 April 2017 to 31 March 2018 (PDF, 579KB)

Workforce Race Equality Standard action plan (PDF)

Workforce Race Equality Standard (WRES) 2017

Workforce Race Equality Standard RBHT - 1 April 2016 to 31 March 2017 (PDF, 575KB)

Workforce Race Equality Standard action plan (PDF, 45KB)

Equality Delivery System 2 (EDS2)

Implementation of the Equality Delivery System EDS2 Summary Report - 2020 (PDF, 693KB)

Implementation of the Equality Delivery System EDS2 Summary Report - 2019 (PDF, 698KB)

Implementation of the Equality Delivery System EDS2 Summary Report - 2018 (PDF, 696KB)

Implementation of the Equality Delivery System EDS2 Summary Report- May 2017 (PDF, 687KB)

Implementation of the Equality Delivery System EDS2 Summary Report - March 2016 (PDF, 684KB)

Public Sector Equality Duty Information 2019

Publication of Information to meet the requirements of the Public-Sector Equality Duty. Period 1 April 2019 - 21 March 2020

Public Sector Equality Duty Information 2018

Public sector duty - Equality Act - Briefing Paper for the Equality & Diversity Steering Group 2018 - 2019 (PDF, 451.8KB)

Public sector duty - Equality Act - Briefing Paper for the Equality & Diversity Steering Group 2017 - 2018 (PDF, 1.5MB)

Public Sector Equality Duty Information 2017

Public sector duty - Equality Act - Briefing Paper for the Equality & Diversity Steering Group 2016 - 2017 (PDF, 737KB)

Employment and healthcare services information - 1 April 2015 to 31 March 2016 (PDF, 1.1MB)

The Single Equality Scheme (SES)

The SES outlines our values and commitments on all equality issues including sexual orientation, age, religion and belief and shows how we intend to provide a fair and personalised specialist care for all. 

Single Equality Scheme (Framework) March 2008 (PDF, 645KB) - approved by the Trust Board on 26.03.2008

Chief executive statement 

The Trust aims to provide excellent public service and needs to ensure propriety and accountability in all matters.

The Trust is determined to protect itself and the public from fraud and corruption and is committed to implementing and maintaining robust policies for the prevention and detection of fraud, bribery and corruption.

The Trust has a zero-tolerance attitude towards fraud, bribery and corruption. The Trust will investigate any suspected acts of fraud, bribery, corruption, misappropriation or irregularity and take full and appropriate action against any wrongdoing.

Robert Bell signature


Read our Anti-bribery policy (PDF, 289KB)

Since 1 January 2005, the Freedom of Information Act allows anyone to request information held by Royal Brompton & Harefield NHS Foundation Trust. 

Find out more about our Freedom of Information policy

Mortality review policy

Learning from deaths is at the heart of the Trust’s ethos to ensure patients, families and carers are at the centre of everything we do. 

Reviewing the care provided to people who have died helps improve care for all patients by identifying where care could be improved, how this relates to outcomes, and working to understand why these occur so that meaningful action can be taken.

Read the Mortality review policy (PDF, 897KB)

Royal Brompton & Harefield NHS Foundation Trust has, for many years, had a policy of screening all patients admitted to the Trust for MRSA. We are therefore fully compliant with the Department of Health’s recent recommendation that all elective and emergency admissions to the Trust are screened for MRSA. Further details of our screening are included within our MRSA policy, which is available for download below. 

MRSA policy - May 2016 (PDF, 487KB)

This policy describes the Trust mechanism for the identification (including screening) and appropriate management (including treatment) of patients and staff who have MRSA.

The Constitution for the Trust sets out how we are run as an organisation. 

It was last updated in November 2019. 

Royal Brompton & Harefield NHS Foundation Trust Constitution - November 2019 (PDF, 932KB)

'Listen, learn, act' 

Royal Brompton & Harefield NHS Foundation Trust has a strong record in patient safety. Performance is monitored continuously, and openness and transparency is encouraged from all staff.

Clinical outcomes are discussed openly and in detail at public board meetings each month, when members of the public and non-executive directors can challenge executive directors if they have any concerns about how services are being delivered.

Governors also undertake a similar role at their council meetings where the same information is presented and discussed. 

Patient safety is an integral part of performance reporting and the Trust was an early supporter of the Patient Safety First! campaign – a national campaign to promote patient safety in a variety of ways. 

A commitment to patient safety comes from the top of the organisation – the Trust board has pledged that creating a safety culture is a shared priority – and should be reflected by every individual, team and department.

Sign up to safety logoSign up to Safety is a national initiative hosted by NHS England with the aim of delivering harm-free care to every patient and halving avoidable harm over the next three years.

All healthcare providers, individuals and organisations are eligible to join and membership requires commitment to develop a safety improvement plan (SIP) based on five pledges:

  • putting safety first
  • continuously learning
  • honesty
  • collaboration
  • supporting staff and patients when things go wrong.

Within Royal Brompton & Harefield NHS Foundation Trust, development and implementation of a SIP based on the five pledges will contribute to the safety domain of our quality and safety strategy 2015-

By joining the Sign up to Safety initiative, the Trust confirms its commitment to improving quality and safety by:

  • describing the actions we will undertake linked to the five pledges
  • developing a SIP to reduce avoidable harm and death
  • identifying those areas on which we will focus our improvement efforts
  • detting out how we will engage with and involve patients, staff and the public
  • making our SIP public and regularly providing updates on our progress.

Over the next three years Royal Brompton & Harefield NHS Foundation Trust pledges to:

Put safety first: commit to reduce avoidable harm and make public our goals and plans

  • Achieve significant reduction in the incidence and impact of acute kidney injury through a suite of measures to improve recognition, and prompt early documented consultant review and appropriate management, especially in at-risk groups such as diabetic patients
  • Further develop the NEWS & PEWS systems for monitoring adult and paediatric patients to ensure prompt identification, escalation and management of deteriorating patients
  • Implement national guidance for the identification and management of sepsis by integrating a sepsis scoring system into our adult and paediatric early warning scoring (EWS) protocols and continue work to reduce surgical site Infections and hospital-acquired infections 
  • Improve care of the elderly (>70 years) with emphasis on reducing falls and improving care and management of delirium, dementia and frailty
  • Set stretch goals of zero never events and 50% reduction in procedural complications
  • Zero new grade three and four pressure ulcers
  • Reduce avoidable cancellations by 50% and improve tracking of patients with zero tolerance of loss to follow-up
  • Improve medical and nursing handover through implementation of a standardised process and ultimately an integrated digital care record by 2018
  • Improve reporting of incidents relating to medication and devices as part of a programme to improve medication and device safety 
  • Develop a comprehensive approach to accessing and acquiring patient experience feedback on all aspects of their care

Continually Learn: make our organisation more resilient to risks by acting on feedback from patients and continuously measuring how safe our services are

  • Make the Trust more resilient by identifying areas of risk through review of serious incidents and incidents linked to the patient advice and liaison service (PALS), complaints, claims, inquests and patient experience feedback
  • Ensure recommendations and action plans from serious incidents, complaints and clinical audits are realistic, implemented in a timely manner, monitored through continuous tracking of recommendations and actions, and reported regularly 
  • Improve capacity and capability for quality improvement by providing access to training for staff 
  • Develop quality and safety dashboards for wards, units, services and care groups, which include sampling errors, reporting and alerting of imaging abnormalities, and patient identification errors
  • Make quality, performance and outcome data available to all staff through divisional reports and intranet pages

Honesty: be transparent with people about progress tackling patient safety issues and support staff to be candid with patients and their families if something goes wrong

Acknowledge when things go wrong – between staff, colleagues, teams, management and clinicians, and with patients.

  • Promote awareness of our duty of candour as an organisation and as healthcare professionals, ensuring openness and transparency with patients supported by appropriate documentation and correspondence 
  • Support for staff in relation to writing of statements, psychological and professional support, training and education 
  • Provide training in being open for relevant staff 
  • Publish quality, safety and outcome data on the Trust website

Collaboration: take a leading role in supporting local collaborative learning so that improvements are made across all the local services that patients use

  • Work with commissioners to ensure safe, high-quality care
  • Work with, engage and involve patients through bespoke events, committees and patient panels to ensure their views are acknowledged and used to guide service delivery and development
  • Commit to the NHS England Sign up to Safety initiative 
  • Become an active participant in the Imperial College Health Partners Patient Safety Collaborative
  • Open an Institute for Healthcare Improvement (IHI) Open School chapter at Royal Brompton & Harefield NHS Foundation Trust with plans to spread across the Trust and partner organisations.
  • Continue to develop links with LiverpooI Heart and Chest Hospital NHS Foundation Trust via Imperial College School of Medicine expanding its remit to include quality and safety improvement 
  • Continue to share our experience of innovation and research


  • Continue to develop and implement human factors and simulation training for all staff groups
  • Continue to promote reflective practice and feedback through clinical governance sessions and Schwartz Rounds 
  • Continue to use an annual staff safety climate survey and ensure each clinical unit addresses one action for improvement.  
  • Develop clear guidance for junior staff (all professions) for reporting and investigation of incidents
  • Enhance new consultant induction, mentoring and introduction to the Trust
Safety Improvement plan RBHNFT 2015-18

Safety improvement plan for RBHNFT 2015-18

The Trust endeavours to make sure that no modern slavery or human trafficking takes place in any part of our business or supply chain.

This statement sets out actions taken by the Trust to understand all potential modern slavery and human trafficking risks and to implement effective systems and control measures. 

Slavery and Human Trafficking Statement 2020-2021 (PDF, 78KB)

Slavery and Human Trafficking Statement 2019-2020 (PDF, 117KB)

Slavery and Human Trafficking Statement 2018-2019 (PDF, 1MB)

Slavery and Human Trafficking Statement 2017-2018 (PDF, 1.1MB)

Slavery and Human Trafficking Statement 2015-2016 (PDF, 1.1MB)

Slavery and Human Trafficking Statement 2016-2017 (PDF, 171KB)

Smokefree logoRoyal Brompton & Harefield NHS Foundation Trust is a smoke-free organisation. Smoking, including the use and charging of e-cigarettes, is banned in all areas of the Trust, including:

  • buildings 
  • doorways / entrances 
  • grounds 
  • cars 
  • car parks.  

No smoking signs are positioned at the site entrances and across the site.  

Why smoke free?

The purpose of the smoke free policy is to protect and improve the health and wellbeing of all employees, visitors, contractors and, most importantly, patients

Smoke free hospitals and grounds create a clean, pleasant environment for people trying to stop smoking and reduce triggers that cause many smokers to relapse.

If smoking occurs at entrances and windows, the smoke drifts through the doors and windows and poses a further hazard to the health and wellbeing of inpatients.

Stop smoking support for patients

If you have an operation booked at the hospital it is a good time to stop smoking; doing so will really help your recovery.  

Our staff are here to help and support you throughout your hospital stay and when you go home

On admission, all patients who smoke will be prescribed nicotine replacement therapy (NRT) and, with their consent, will be referred to our smoke-free team or provided with details for the NHS stop smoking service. They will provide advice, support and treatment following discharge from hospital.

Stop smoking support for relatives, visitors and members of the public

Family and friends who wish to stop smoking long term should contact their GP practice or the NHS stop smoking service on 0800 0221 4332 for support quitting.

What will happen if I don’t comply?

Patients will be given all the support they need to comply with the smoke-free policy and prescribed NRT products to ease withdrawal symptoms during their stay in hospital. Any patient smoking on site will be asked to stop smoking and extinguish their cigarette.

The Trust will take it very seriously if anyone is found smoking in dangerous places on hospital property.

If you are found to be smoking within Trust grounds, a member of staff will politely ask you to stop before explaining why the Trust is smoke-free and ways to help you stop smoking.

The Trust has zero tolerance to violence. If members of the public persist in smoking or become abusive or aggressive when asked to stop, they will be asked to leave the site.

The NHS Constitution states that patients have a right to access NHS consultant-led services within the maximum waiting time of 18 weeks, unless the patient chooses to wait longer, or it is in the best clinical interest of the patient to delay the start of treatment.

The target is that 92 per cent of patients currently waiting for their inpatient or outpatient treatment must have waited less than 18 weeks.

The Royal Brompton & Harefield NHS Foundation Trust did not consistently meet the target for 2015/16. The Trust has agreed a remedial action plan with NHS England which is designed to deliver the agreed trajectory during 2016/17.

The policy below shows how we offer appointments and admissions to patients.

The NHS Choices website has further information for patients.

Waiting list policy for 18 weeks, elective inpatients and outpatients [pdf / 433KB] Updated September 2015