SH FP 4. Version 2. Summary:

Transcription

1 SH FP 4 Summary: This explains the steps that must be taken by staff and managers where fraud, bribery or corruption is suspected or discovered. Having appropriate measures in place helps to protect NHS resources against crime and ensures they are used for their intended purpose, the delivery of patient care. Any person who becomes aware of any fraud, bribery or other illegal act and does not follow this policy could be subject to disciplinary action. The Trust has nominated Local Counter Fraud Specialists who staff should contact promptly and in confidence if they have any concerns that fraud may have taken place. This supersedes all previous counter fraud policies produced at Southern Health NHS Foundation Trust. Keywords (minimum of 5): (To assist policy search engine) Target Audience: Fraud, Bribery, Corruption, LCFS, Whistleblowing, Forgery, Crime. All employees should be aware of this policy, while managers must bring its contents to the attention of their staff. Next Review Date: June 2019 Approved and Ratified by: Audit, Assurance & Risk Committee. Date of meeting: 22 May 2017 Date issued: June Author: Sponsor: Kim Hampson, Local Counter Fraud Specialist Paula Anderson, Chief Finance Officer 1

2 Version Control Change Record Date Author Version Page Reason for Change July 2015 March 2017 David Bennett V1 16 Update contact details of LCFS to reflect change in Counter Fraud provider. Policy review no further changes review date extended to 2017 Kim Hampson V2 Policy review, title change Reviewers/contributors Name Position Version Reviewed & Date David Bennett Local Counter Fraud Specialist V1, July 2015 Kim Hampson Local Counter Fraud Specialist, TIAA Ltd V2, March

3 Contents Page 1. Introduction 4 2. Scope 4 3. Definitions 5 4. Duties/ responsibilities 6 5. The Fraud Response Plan Training requirements Monitoring compliance Policy review Associated documents 13 Appendices A1 Nolan Principles 14 A2 NHS Fraud: Do s and Don ts - A Desktop Guide for Southern 15 Health NHS Foundation Trust A3 Training Needs Analysis (TNA) 16 A4 Equality Impact Assessment (EqIA) 17 3

4 1. Introduction 1.1 This document sets out the Southern Health NHS Foundation Trust s (the Trust s ) policy and response for detected or suspected fraud, bribery and or corruption. 1.2 One of the basic principles of public sector organisations is the proper use of public funds. It is therefore important that all those who work in the public sector, are aware of the risks of fraud, and other illegal acts involving dishonesty. The Trust as an organisation is committed to the seven principles of public life, expounded in the Nolan Committee report and as listed in Appendix 1. All those who work in the organisation should be aware of, and act in accordance with these values. 1.3 Southern Health NHS Foundation Trust adopts a zero tolerance policy to fraud, bribery, corruption, money laundering or any similar illegal act within the NHS. The aim is to eliminate all fraud within the NHS as far as possible and the Trust will seek the appropriate disciplinary, regulatory, civil and criminal sanctions against those who commit fraud, and will attempt to recover losses whenever possible. The Trust already has procedures in place that reduce the likelihood of fraud occurring. These include standing orders, standing financial instructions, documented procedures and systems of internal control and risk assessment. In addition, the Trust seeks to ensure that a risk and fraud awareness culture exists in the Trust. 1.4 This document explains the Trust s and the steps that must be taken where fraud, bribery or corruption is suspected or discovered. All staff should be aware of this while managers must bring its contents to the attention of their staff. Staff should note: Any person who becomes aware of any fraud, bribery, money laundering or other illegal act and does not follow this policy could be subject to disciplinary action. 1.5 The Trust has nominated Local Counter Fraud Specialists (LCFS) who staff should contact promptly and in confidence if they have any concerns that fraud may have taken place. Their contact details are listed in Appendix 2 in this policy. 2. Scope 2.1 This policy applies to all staff, and for the avoidance of any doubt any reference to staff in this policy will include any temporary staff, e.g. agency staff, locums, volunteers or contractors employed by the Trust. For simplicity all such offences are hereafter referred to as Fraud, except, where the context indicates otherwise. 2.2 The LCFS will investigate any fraud that may cause a loss to the NHS, and this may include internal fraud i.e. committed by an employee, or external including an individual, supplier or a criminal organisation. The LCFS may also investigate any fraud committed against a patient and where the Trust has some responsibility, e.g. involving patient s money where the Trust has responsibility for safe keeping. 2.3 The NHS Standard Contract published by NHS England requires all provider NHS bodies to maintain appropriate counter fraud and security management arrangements. Service condition 24 of this Contract places all the obligation to have such arrangements in place, on providers of NHS services. 4

5 3. Definitions Fraud 3.1 The Fraud Act 2006 came into force on 15 January 2017 and applies in England, Wales and Northern Ireland. The focus is on the dishonest behaviour of the subject and their intent to make a financial gain or cause a financial loss. The gain or loss does not have to succeed as long as the intent is there. 3.2 The offence of fraud can be committed in a number of ways. The more common ones are: Fraud by false representation (Section 2) a representation can be in words, written or communicated by conduct. There must be knowledge that the representation is false or misleading Fraud by failing to disclose (Section 3) not declaring something verbally or in writing when there is a legal duty to disclose that information Fraud by abuse of a position of trust (Section 4) abusing a position where there is an expectation to safeguard, or not act against, the financial interests of another person or organisation. 3.3 The following are examples although this is not a definitive list as fraudsters are continually devising new ways to defraud organisations and people for personal gain; Fraud by false representation (s.2) Submitting a timesheet or an expense claim which is known to be false, e.g. for a shift that has not been worked or deliberately inflating expenses mileage. NB The claim doesn t have to be processed or paid; an offence may have occurred if you present such a claim to your manager for authorisation; Misusing sick leave by undertaking other employment at the same time; Making a petty cash claim that is false, e.g. by presenting fake receipts; Saying that you attended a training course or a conference paid for by the NHS when in fact you did not; A supplier charging for goods and services that were not actually delivered; Presenting a fake passport, right-to-work visa, reference or qualification to gain employment with the Trust; or Fraud by abuse of a position of trust (s.4) Person who cares for a vulnerable patient and has access to their bank account withdraws money for their own use; A finance officer transfers money from a Trust account to their own; Providing information about a procurement exercise to a supplier that wasn t available to others; or Supplying a false reference to enable a person to gain employment. Bribery 3.4 In July 2011, the Bribery Act 2010 came into force reforming the criminal law of bribery, enabling simpler prosecution of offences. The Act created a new corporate offence. A relevant commercial organisation (e.g. the Trust or any NHS organisation) is guilty of an offence if a person associated with the organisation bribes another person or receives a bribe to obtain an advantage. However it is a defence for the organisation to prove that it had in place adequate policies and procedures designed to prevent persons from undertaking such conduct. 5

6 3.5 The relevant sections of the Bribery Act are:- Section 1 Offences of bribing another person; Section 2 Offences related to being bribed; Section 6 Bribing a foreign public official; and Section 7 Failure of commercial organisations to prevent bribery. 3.6 Simply put it can be defined as accepting an incentive to do something which they would not normally do. For example; If a person were responsible for recruiting an individual to join the Trust and they were offered and accepted tickets to an event by one of the candidates to give them preferential treatment; or If a person was responsible for purchasing goods or services and they were offered and accepted a meal by a supplier to accept a contract; Both the person offering a bribe and the person accepting it would be guilty of committing an offence under the Bribery Act Further details can be found in the Trust s Business Conduct Policy Declaration of Interests, Gifts, Hospitality and Sponsorship. Money Laundering 3.7 Money laundering is a process by which the proceeds of crime are converted into assets which appear to have a legitimate origin, so that they can be retained permanently or recycled into further criminal enterprises. 3.9 Offences covered by the Proceeds of Crime Act 2002 and the Money Laundering Regulations 2007 may be considered and investigated in accordance with this Policy The NHS could become indirectly involved in this act where the proceeds of any crime, e.g. fraud, are converted by making a payment to the Trust and then seeking immediate repayment. Theft 3.12 A person is guilty of theft if they dishonestly appropriates property belonging to another with the intention of permanently depriving the other of it. Such cases where the theft is obvious, i.e. after a break-in or where a loss is immediately noted should be referred to the Police and/or the Trust s Local Security Management Specialist (LSMS). 4. Duties / Responsibilities 4.1 This section sets out the Trust s policy on dealing with fraud. The Trust is absolutely committed to maintaining an honest, open and well-intentioned atmosphere within the Trust. It is therefore also committed to the elimination of any fraud within the Trust, and to the rigorous investigations of any such cases. The Trust wishes to encourage anyone having reasonable suspicions of fraud to report them. Therefore, it is also the Trust s policy, which will be rigorously enforced, that no employee will suffer in any way as a result of reporting reasonably held suspicions. All members of staff can therefore be confident, that the Trust will do everything possible to ensure that they will not suffer in any way as a result of reporting reasonably held suspicions of fraud. For these purposes, reasonably held suspicions shall mean any suspicions other than those, which are raised maliciously and found to be groundless. 6

7 4.2 The NHS Standard Contract requires the provider to ensure that NHS Protect or the appointed LCFS is given access to property, premises, information and staff for the purpose of detecting and investigating cases of fraud, bribery and corruption. 4.3 NHS Protect NHS Protect provides national leadership for all NHS anti-crime work and is responsible for strategic and operational matters in relation to anti-fraud, bribery and corruption work across the NHS. NHS Protect was restructured from 1 April 2017 and the local Area Anti-Fraud Specialist support and advice role ceased to exist. However a Crime Reduction Unit was established to design fraud prevention solutions and develop guidance for local specialists and NHS organisations on countering fraud. NHS Protect will continue to retain its National Investigation Service (NIS), including its financial investigation and forensic computing capability. NIS also retain functions that support the pursuit of sanctions against those who commit fraud against the NHS, and criminal proceedings will still be progressed through the Specialist Fraud Division of the Crown Prosecution Service 4.4 The Chief Executive As the Accountable Officer, the Chief Executive has the ultimate responsibility for funds entrusted to the Trust. The Chief Executive will ensure that adequate policies and procedures are in place to protect the Trust and the public funds entrusted to it, and this includes dealing with any allegations, or instances of fraud, bribery and corruption within the Trust. Within these constraints, the responsibility for investigating is delegated to the Director of Finance to deal with on a day-to-day basis. 4.5 The Director of Finance The Director of Finance is provided with powers to approve financial transactions initiated by directorates across the Trust. The Director is responsible for maintaining an effective system of internal financial control including ensuring that detailed financial procedures and systems incorporating the principles of separation of duties and internal checks are maintained. The Director will, depending on the outcome of initial investigations, inform appropriate senior management of suspected cases of fraud, bribery and corruption, especially in cases where the loss may be above an agreed limit or where the incident may lead to adverse publicity. The Director of Finance is the Nominated Officer for the Trust for the purposes of this policy. As a senior officer of the Trust, together with the LCFS, they are authorised to receive allegations of fraud and bribery confidentially and anonymously. The Director will normally inform the LCFS and delegate to the LCFS responsibility for leading any fraud investigation whilst retaining overall responsibility themselves. The Director shall also be responsible for informing third parties such as senior management, Internal Audit or External Audit when appropriate. Where a member of staff is to be interviewed or disciplined, the Director or the LCFS will consult and take advice from the Associate Director for Workforce Delivery. 4.6 The Associate Director for Workforce Delivery and Human Resources The Associate Director for Workforce Delivery shall advise those involved in any fraud investigation on matters of employment law, and other procedural matters, such as disciplinary and complaints procedures. The Director will agree an LCFS/HR Protocol to enable the effective interaction with the Human Resources department. The protocol is a framework detailing the liaison responsibilities whenever a potential fraud is highlighted, and helps to ensure that the 7

8 full range of sanctions available can be considered at the earliest opportunity (criminal, disciplinary and civil). Whilst there will be close liaison between the LCFS and HR, there is still a need to maintain independence of their concurrent investigations. The LCFS and HR will share information where it is appropriate and lawful to avoid duplication and to ensure that parallel sanctions are effectively applied in a coordinated manner. 4.7 The Local Counter Fraud Specialist The LCFS has been specifically trained in counter fraud procedures, and has been accredited by NHS Protect to undertake work in this field. The LCFS will work with all staff and stakeholders to promote anti-fraud work and effectively respond to system weaknesses and investigate allegations of fraud, bribery and corruption. The LCFS has a number of duties to perform, including: Receive any fraud, bribery or corruption referral directly from staff, the public or a contractor; Investigate all cases of fraud within the Trust and to report upon these to the Director of Finance; Liaise with other relevant parties as necessary, e.g. HR; Publicise counter fraud work and the fraud awareness message within the Trust; Undertake local proactive counter fraud work with the aim of fraud prevention, detection and deterrence; Report any system weakness to the Director of Finance; Liaise with NHS Protect and report any case and the outcome of the investigation through the NHS Protect case management system. The LCFS will adhere to the Counter Fraud Professional Accreditation Board s Principles of Professional Conduct. 4.8 All Staff All staff have a duty to ensure that public funds are safeguarded, whether or not they are involved with cash or payment systems, receipts or dealing with contractors or suppliers. They must also protect Trust assets including information and goodwill, as well as property. The Trust has various policies and procedures in place including Standing Orders and Standing Financial Instructions, which also place an obligation on all staff and to act in accordance with best practice. In addition staff have a responsibility to comply with all applicable laws and regulations relating to ethical business behaviour, procurement, personal expenses, conflicts of interest, confidentiality and the acceptance of gifts and hospitality. This means, in addition to maintaining the normal standards of personal honesty and integrity, all employees should always: Avoid acting in any way which might cause others to suspect them of dishonesty Behave in a way which would not give cause for others to doubt that Trust employees deal fairly and impartially with official matters Be alert to the possibility that others might be attempting to defraud. Staff who are part of a professional body have a personal responsibility to ensure that they are familiar with their standards and act in accordance with them. Further details can be found in the Trust s Business Conduct Policy Declaration of Interests, Gifts, Hospitality and Sponsorship. If staff suspect that there has been fraud, or has seen any suspicious acts or events, they must report the matter to the nominated LCFS or to NHS Protect. 8

9 4.9 Managers Managers must be vigilant and ensure that procedures to guard against fraud are followed. They should be alert to the possibility that unusual events or transactions could be symptoms of fraud, and where they have any doubt they must seek advice from the LCFS or the Director of Finance. Managers must instil and encourage an anti-fraud culture within their team and ensure that information on procedures is made available to all staff. The LCFS will proactively assist the encouragement of an anti-fraud culture by undertaking work that will raise fraud awareness. All instances of actual or suspected fraud, bribery or corruption, which come to the attention of a manager, must be reported immediately to the LCFS or NHS Protect. Managers should not inform the subject that they are making a referral or seeking advice from the LCFS. It is appreciated that some staff will initially raise concerns with their manager, however, in such cases managers must not attempt to investigate the allegation themselves, and they have the clear responsibility to refer the concerns to the LCFS as soon as possible. Line managers, at all levels, have a responsibility to ensure that an adequate system of internal control exists within their areas of responsibility and that controls operate effectively. The responsibility for the prevention and detection of fraud therefore primarily rests with managers but requires the co-operation of all staff. As part of that responsibility line managers need to: Inform staff of the Trust s Business Conduct Policy and this Anti-Fraud, Bribery and Corruption Policy as part of their induction process, paying particular attention to the need for staff to complete accurate claims, records and/or forms; Assess the types of fraud and bribery risk involved in the operations for which they are responsible; Ensure that adequate control measures are in place to minimise the above risks. This must include clear roles and responsibilities; supervisory checks; staff rotation, (particularly in key posts); separation of duties wherever possible, so that control of a key function is not invested in one individual; and regular reviews, reconciliations and test checks to ensure that control measures continue to operate effectively; Ensure compliance with the above controls; Ensure that those in financially sensitive posts receive appropriate supervision; Ensure that any use of Trust IT equipment by staff is linked to the performance of their duties within the Trust; Be aware of the rules and guidance covering the control of specific items of expenditure and receipts; and Contribute to their Director s assessment of the risks and controls within their business area, which feeds into the Accounting Officer s overall statements of accountability and internal control. The LCFS has prepared a guide at Appendix 2 which provides a reminder of the key contacts and a checklist of the actions to follow if fraud, bribery and/or corruption, is discovered or suspected. Managers are encouraged to copy this to staff and to place it on staff notice boards Information Management and Technology The Computer Misuse Act 1990 makes activities illegal, such as hacking into other people s systems, misusing software, or helping a person to gain access to protected files of someone else's computer a criminal offence. The Director of IT will contact the LCFS in all cases where there is suspicion that IT is being used for offences under the Act or fraudulent purposes. Human Resources will also be informed if there is a suspicion that an employee is involved. 9

10 4.11 Local Security Management Specialist The Local Security Management Specialist is responsible for the investigation of security related incidents, in particular the investigation of acts of violence or aggression toward staff, and theft of or damage to Trust property. Where necessary the LSMS will liaise with the LCFS to enable them to investigate cases of fraud Internal and External Audit The LCFS will report details of any systems weaknesses in the internal control environment that they have identified that are a fraud risk or may have allowed fraud to take place. Similarly the Trust s Internal and External Auditors will report to the LCFS any suspicion of fraud and any systems weaknesses detected in the course of their work that may allow fraud to take place. 5. The Fraud Response Plan 5.1 Reporting fraud or corruption If you have any reason to suspect a colleague, patient, contractor or other person of fraud or an offence against the Trust or a serious infringement of Trust or NHS rules, you have a responsibility to inform the LCFS, or the Director of Finance. Should any employee wish to contact an alternative person, it is suggested they refer to paragraph of the Speak Up Procedure (Whistleblowing) SH HR 13 which provides full details of alternative contacts. Staff may also contact the NHS Fraud & Corruption Reporting Line (Freephone Monday to Friday 8am-6pm), where they may also report any concerns they may have relating to suspected fraud including making an anonymous referral. They can also make a report online at again this can include an anonymous referral. All reports of fraud, bribery and corruption will be taken seriously and thoroughly investigated. All referrals will be treated in the strictest of confidence. 5.2 LCFS contact details The LCFS contact details are [click here] or can be found at Appendix 2 below. 5.3 Reporting fraud anonymously Where you choose to report fraud anonymously please provide as much detail as possible including names, times, dates and locations. We would encourage you to contact us in confidence as your name will not be divulged, e.g. to the Trust, unless there was evidence that you had committed an offence. All information including your referral will be treated in the strictest confidence. Any evidence you may have relating to a fraud can be sent anonymously by post to us at [click here]. 5.4 Policy on Speaking Up (Whistleblowing) The Trust wants all employees to feel confident that they can expose any wrongdoing without any risk to themselves. In accordance with the provisions of the Public Interest Disclosure Act 1998, the Trust has produced a Speak Up (Whistleblowing) Policy, (SH HR 12) and Speak up (Whistleblowing) Procedure (SH HR 13) 10

11 This policy is intended to complement the Trust s Anti- Fraud, Bribery and Corruption Policy and Business Conduct Policy and ensures there is full provision for raising your concerns with others if you do not feel able to raise them with your line manager/management chain. It can be found under Policies on the Trust s Intranet or on the link in the previous paragraph. The main message of this policy is if something is troubling a member of staff and they think the Trust should look into it, SPEAK UP. The Trust would prefer that matters are raised when they are identified as a concern, rather than waiting for proof. If in doubt raise it. This document makes it clear that staff can do so without fear of reprisals, victimisation or subsequent discrimination. 5.5 Investigation The LCFS investigation will focus on obtaining information about whether fraud, bribery or corruption is indeed present in a specific case, collating that information and supplying it as evidence so that any appropriate sanction can be sought, and making it available so any lost resources can be recovered. Where deficiencies are identified as a result of an investigation, the LCFS will make a report to the Trust with recommendations to strengthen the systems of control that manage key areas of fraud risk. The Trust s Audit, Assurance & Risk Committee will see a summary of all LCFS reports and proactive work and monitor the implementation of recommendations. 5.6 Sanctions and Redress This section outlines the sanctions that can be applied and the redress that can be sought against individuals who commit fraud, bribery and corruption against the Trust and should be read in conjunction with the Trust s Disciplinary Policy SH HR 28/29. Where staff are believed to be involved in any fraud, the LCFS will inform the Director of Workforce and Development or relevant HR Manager and follow the LCFS/HR Protocol. Further details can be found in the Trust s Disciplinary Policy SH HR 28/29, and can be found under Policies on the Trust s Internet. The types of sanction which the Trust may apply when an offence has occurred are as follows: Civil Civil sanctions can be taken against those who commit fraud, bribery or corruption, to recover money and/or assets which have been fraudulently obtained Criminal The Local Counter Fraud Specialist will work in partnership with NHS Protect, the police and the Crown Prosecution Service, to bring a case to court against an offender. Outcomes, if found guilty, can include fines, a community order or imprisonment and a criminal record. Disciplinary Disciplinary procedures will be initiated when an employee is suspected of being involved in fraudulent or illegal activity. Further information can be found in the Trust s Disciplinary Policy and Procedure. Professional body disciplinary An employee may be reported to their professional body as a result of an investigation or prosecution. 5.7 Recovery of monies lost through fraud One of the key aims of the Trust s Counter Fraud Strategy is to maximise resources for patient care and services, thus where there is evidence that fraud has occurred it 11

12 will seek to recover this. This will limit the financial impact, help to deter others from committing fraud and minimise any reputational damage to the Trust. Recovery can take place in a number of ways: Through the Criminal Court by means of a Compensation Order; Through the Civil Courts or a local agreement between the Trust and the offender to repay monies lost; In cases of serious fraud, NHS Protect can apply to the courts to make an order concerning the restraint and confiscation of the proceeds of criminal activity. The purpose is to prevent the disposal of assets, e.g. abroad which may be beyond the reach of the UK criminal system; or For employees in the NHS Pension scheme, any benefits or other amounts payable can be reduced. The Pensions Act 1995 specifically states: If a loss of public funds occurs because of a member s criminal, negligent or fraudulent act or omission, the Secretary of State, may reduce any benefits or other amounts payable to, or in respect of, the member by any amount equal to the loss. 6. Training Requirements 6.1 Training will be provided, as appropriate, to new members of staff as part of the induction process. The existence and scope of this Policy will be brought to the attention of all staff through information exchange, fraud newsletters and any other method considered relevant, i.e. dedicated workshops/training events, or individual discussions. 6.2 Specific training will also be provided for managers to ensure they have the knowledge, skills and awareness necessary to operate this policy and procedure efficiently and effectively and to communicate it to their staff. 6.3 The LCFS will be available to attend departmental or team meetings to provide information on fraud and the steps that the NHS is taking to try to reduce and eliminate it. Ideally these awareness sessions should be two-way with the LCFS listening and discussing any concerns that staff might have. The LCFS will provide posters, leaflets and newsletters for staff to take back to their unit. All sessions can be tailored to individual needs, from formal with slides to an informal discussion, e.g. at shift handover. Training can be arranged by the LCFS contact details are on the attached appendices. 6.4 The LCFS has a page on the Trust intranet with more information about fraud, bribery and corruption. 6.5 The LCFS can also arrange longer workshops where the fraud risk associated with a specific part of the Trust can be discussed, examples have included procurement and HR recruiting, but the LCFS will be happy to consider other areas/groups. 7. Monitoring Compliance 7.1 The LCFS will monitor policy effectiveness, which is essential to ensure that controls are appropriate and robust enough to prevent or reduce fraud, bribery and corruption. Arrangements will include reviewing system controls on an ongoing basis and identifying weaknesses in processes. 7.2 Where deficiencies are identified as a result of monitoring, appropriate recommendations and action plans will be implemented and taken into consideration when this policy is reviewed. 12

13 7.3 The LCFS will provide an annual report on work to counter fraud, bribery and corruption to the Audit, Assurance & Risk Committee, as well as progress reports throughout the year. 8. Policy Review 8.1 The policy will be reviewed bi-annually by the Trust, supported by LCFS to ensure that the policy is still fit for purpose and meets the latest guidance and legislative changes, and any updates will be reviewed and approved by the relevant Expert Group. 9. Associated Documents Disciplinary Policy SH HR 28 Disciplinary Procedure SH HR 29 Speaking Up (Whistleblowing) Policy SH HR 12 Speaking Up (Whistleblowing) Procedure SH HR 13 Business Conduct Policy (Declaration of Interests, Gifts, Hospitality and Sponsorship) Staff Terms and Conditions Standing Financial Instructions, Standing Orders (contained within the Terms of Authorisation) and Scheme of Delegation. Financial Procedures - SH FP 1 Nolan Principles - Appendix 1 NHS Fraud: Do s and Don ts - A Desktop Guide for Southern Health NHS Foundation Trust - Appendix 2 13

14 APPENDIX 1 Nolan Principles Selflessness: Integrity: Objectivity: Accountability: Openness: Honesty: Leadership: Decisions must be made solely in terms of public interest, not in order to gain personal financial or other benefits. Directors and staff should not place themselves under any obligation to third parties. In carrying out Trust business all appointments, contracts and recommendations must be made on merit. Directors and employees of the Trust are accountable for their decisions and actions. The Trust Board and Directors will be as open as possible on all decisions and actions taken. Directors and employees have a duty to declare any private interests which may impact on their Trust duties. The Trust Board and Directors will support these principles by leadership and example. 14

15 Appendix 2 FRAUD is the intent to obtain a financial gain from, or cause a financial loss to, a person or party through false representation, failing to disclose information or abuse of position. BRIBERY & CORRUPTION is the deliberate use of payment or benefit-in-kind to influence an individual to use their position in an unreasonable way to help gain advantage for another. DO Note your concerns Record details such as the nature of your concerns, names, dates, times, details of conversations and possible witnesses. Time, date and sign your notes. Retain evidence Retain any evidence that may be destroyed, or make a note and advise your Local Counter Fraud Specialist (LCFS). Report your suspicions Confidentiality will be respected delays may lead to further financial loss. DO NOT Confront the suspect or convey concerns to anyone other than those authorised, as listed below Never attempt to question a suspect yourself; this could alert a fraudster or lead to an innocent person being unjustly accused. Try to investigate, or contact the police directly Never attempt to gather evidence yourself unless it is about to be destroyed; gathering evidence must be done in line with legal requirements in order for it to be useful. Your LCFS can conduct an investigation in accordance with legislation. Be afraid of raising your concerns The Public Interest Disclosure Act 1998 protects employees who have reasonable concerns. You will not suffer discrimination or victimisation by following the correct procedures. Do nothing! If you suspect that fraud against the NHS has taken place, you must report it immediately, by contacting: The LCFS (details below), or The Director of Finance (Paula Anderson), or Telephoning the Freephone NHS Fraud and Corruption Reporting Line ( ). Do you have concerns about a fraud taking place in the NHS? Calls to the NHS Fraud and Corruption Reporting Line: will be treated in confidence and investigated by professionally trained staff. Online: Your Local Counter Fraud Specialists are Andrew Morley and Kim Hampson who can be contacted by telephoning or , or ing Andrew.Morley2@nhs.net or Kim.Hampson@nhs.net If you would like further information about NHS Protect, please visit Tackling fraud 15

16 Appendix 3 LEaD (Leadership, Education & Development) Training Needs Analysis If there are any training implications in your policy, please complete the form below and make an appointment with the LEAD department (Louise Hartland, Strategic Education Lead or Sharon Gomez, Essential Training Lead on ) before the policy goes through the Trust policy approval process. Training Programme Title and Level (if appropriate) of your training programme Directorate Frequency Course Length Delivery Method Trainer(s) How often will the target audience need to attend this course? Division Adult Mental Health How long will the programme run (April April?) and how long will each course take (3 hours?) How and where do you intend delivering this programme (face to face, e-learning, Essential Training Days)? Who will be delivering this programme if delivery method is face to face? Recording Attendance Who do you anticipate recording attendance? Strategic & Operational Responsibility Who is accountable for this training strategically and who is operationally accountable? Target Audience Please identify exactly which staff groups you expect to attend this course for each division. Please state n/a as appropriate e.g. All clinical support staff and all qualified clinical staff or Any person with responsibility to manage others MH/LD ICS Corporate Services Learning Disability Services Older Persons Mental Health Specialised Services TQtwentyone Adults Children s Services Specialist Services All (Workforce & Development, Finance & Estates, Commercial) All Trust staff need to have some fraud awareness. This is currently started at induction with a refresher provided on an ad hoc and targeted basis throughout the year at team meetings or awareness days. In addition there are newsletters, leaflets and other promotional material distributed by LCFS, an annual fraud awareness survey which staff are encouraged to complete, and there are fraud pages on the Trust s intranet plus specific reminders sent via the weekly bulletin. Specific workshops relevant to each service needs will take place where there is detailed discussion about fraud risks in that department 16

17 Equality Impact Analysis Screening Tool Appendix 4 Equality Impact Assessment (or Equality Analysis ) is a process of systematically analysing a new or existing policy/practice or service to identify what impact or likely impact it will have on protected groups. It involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. The form is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by equality law. Name of policy/service/project/plan: Policy Number: SH FP 4 Department: Finance Lead officer for assessment: Kim Hampson LCFS Date Assessment Carried Out: 20/03/17 1. Identify the aims of the policy and how it is implemented. Key questions Answers / Notes Briefly describe purpose of the policy including How the policy is delivered and by whom Intended outcomes Provide brief details of the scope of the policy being reviewed, for example: Is it a new service/policy or review of an existing one? Is it a national requirement? Policy will be available on the internet and publicised to staff once ratified. Fraud will be deterred or at least kept to a minimum. Any allegations of fraud, bribery and corruption are investigated promptly to determine whether there is evidence of any offence and that appropriate sanctions and prevention action is applied. Review and update of previous Counter Fraud policy taking into account current national guidance provided by NHS Protect. Yes it is a national requirement. 2. Consideration of available data, research and information. Monitoring data and other information involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. It can help you to identify practical steps to tackle any negative effects or discrimination, to advance equality and to foster good relations. Please consider the availability of the following as potential sources: Demographic data and other statistics, including census findings Recent research findings (local and national) Results from consultation or engagement you have undertaken Service user monitoring data Information from relevant groups or agencies, for example trade unions and voluntary/community organisations 17

18 Analysis of records of enquiries about your service, or complaints or compliments about them Recommendations of external inspections or audit reports Key questions Data, research and information that you can refer to 2.1 What is the equalities profile of the team See below delivering the service/policy? 2.2 What equalities training have staff received? Local Counter Fraud Specialists are provided by TIAA Ltd where equalities training is mandatory. Such training was also part of the LCFS accreditation course. 2.3 What is the equalities profile of service users? Not known. 2.4 What other data do you have in terms of service users or staff? (e.g. results of customer satisfaction surveys, consultation findings). Are there any gaps? 2.5 What internal engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? Service users/carers/staff 2.6 What external engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? General Public/Commissioners/Local Authority/Voluntary Organisations The policy is not gender or race specific, nor refers to any specific equality group. 18

19 In the table below, please describe how the proposals will have a positive impact on service users or staff. Please also record any potential negative impact on equality of opportunity for the target: In the case of negative impact, please indicate any measures planned to mitigate against this: Age Positive impact (including examples of what the policy/service has done to promote equality) None Negative Impact None Action Plan to address negative impact Actions to overcome problem/barrier Resources required Responsibility Target date Disability None Yes Gender None None Reassignment Marriage and Civil Partnership Pregnancy and Maternity Race None Yes Religion or Belief None None Sex See * See * LCFS As req d See ^ See ^ Trust As req d Sexual Orientation * Where any person has a visual impairment we will provide the policy in a form that they are able to access e.g. large print or Braille formats. The Policy does refer to a national fraud & corruption reporting line which would not be immediately accessible to a person with a hearing disability; however there is an online reporting form. ^ Where any person does not have English as their first language we will request that the Trust provides access to language line interpreter services if requested. 19

20 List in the table below level of engagement/consultation with target groups: Target Group Engagement/Consultation carried out Service Users & Carers Staff General Public Not applicable The NHS Standard Contract published by NHS England requires all provider NHS bodies to maintain appropriate counter fraud and security management arrangements this also includes complying with a series of standards. Standard 2.2 states: The organisation has an antifraud, bribery and corruption policy that follows NHS Protect's strategic guidance, publicises NHS Protect s Fraud and Corruption Reporting Line and online reporting tool, and has been approved by the executive body or senior management team. The policy is reviewed, evaluated and updated as required, and levels of staff awareness are measured. CCG Commissioners Local Authorities Voluntary Organisations Other Stakeholders 20