ANTI-FRAUD, BRIBERY AND CORRUPTION POLICY

Agenda Item 14.4 ANTI-FRAUD, BRIBERY AND CORRUPTION POLICY Policy Title Version: 5.0 Approved by: Date of approval: Anti-Fraud, Bribery and Corruption Policy Trust Board TBC Policy supersedes: Counter Fraud Policy V4.1 Lead Board Director: Policy Lead: (and author if different): Name of responsible committee / group: Date issued: Review date: Target audience: Tony Whitfield, Director of Finance David Gregory, Head of Internal Audit Richard Schmidt, Lead LCFS (Author) Audit Committee TBC (Usually 2 years from approval date) Accountability Chief Executive & Director of Finance Responsibility Managers and Supervisors in corporate & operational functions Implementation all Trust staff Keywords Fraud, Bribery, Corruption Local Counter Fraud Specialist (LCFS) 1

Agenda Item 14.4 Contents Paragraph Page Staff Summary 3 1 Purpose 4 2 Background / Context 4 3 Definitions 4 4 Policy Effect 5 5 Roles and Responsibilities 5 6 Equality Analysis 7 7 Consultation and Review Process 7 8 Standards / Key Performance Indicators 7 9 Process for Monitoring Compliance and Effectiveness 7 10 References 10 Appendix A Reporting Fraud, Bribery and Corruption in the NHS 11 Annex 1 Equality Analysis Annex 2 Plans for Communication and Dissemination Annex 3 Checklist for Review and Approval Annex 4 Version Control Template (for draft policies only) 2

Agenda Item 14.4 STAFF SUMMARY One of the basic principles of public sector organisations is the proper use of public funds. The majority of people who work in the NHS are honest and professional and they find that fraud, bribery and corruption, which is often committed by the minority, is wholly unacceptable as it ultimately leads to a reduction in the resources available for patient care. The Trust is committed to the public service values of integrity, accountability and openness. The Trust is also committed to raise awareness and enforce the message that fraud, bribery and corruption within the NHS is not acceptable and will not be tolerated. This policy is developed to encourage anyone having genuine suspicions of fraud, bribery or corruption to report them appropriately. 3

Agenda Item 14.4 1 PURPOSE The purpose of this policy is to: set out the Trust s commitment to reducing the level of fraud, bribery and corruption within both the Trust and the wider NHS to an absolute minimum, keeping it at that level and freeing up public resources for better patient care. make clear that Trust does not tolerate fraud, bribery and corruption and aims to eliminate all such activity as far as possible. encourage anyone having genuine suspicions of fraud, bribery or corruption to report them appropriately. Failure to follow this policy could result in the instigation of disciplinary procedures. 2 BACKGROUND / CONTEXT One of the basic principles of public sector organisations is the proper use of public funds. The majority of people who work in the NHS are honest and professional and they find that fraud, bribery and corruption, which is often committed by the minority, is wholly unacceptable as it ultimately leads to a reduction in the resources available for patient care. It is therefore important that all those who work in the public sector are aware of the risk of and means of enforcing the rules against fraud, bribery and corruption. 3 DEFINITIONS NHS Protect: is the operating name of the NHS Counter Fraud and Security Service and is an independent division of the NHS Business Services Authority (NHS BSA). Fraud The Fraud Act 2006 creates a criminal offence of fraud and defines three ways of committing it: Fraud by false representation, Fraud by failing to disclose information and, Fraud by abuse of position. For fraud to occur, the offenders conduct must be dishonest and their intention must be to make a gain, or cause a loss (or the risk of a loss) to another. Fraud carries a maximum sentence of 10 years imprisonment. Bribery and Corruption The Bribery Act 2010 creates a criminal offence of bribery and defines three ways of committing it: 4

Agenda Item 14.4 individuals who give, promise or offer bribes, individuals who request, agree to receive or receive bribes, companies who fail to prevent bribery. The Bribery Act 2010 introduced a corporate offence which means that organisations, including NHS Bodies, will be exposed to criminal liability for failing to prevent bribery. Bribery carries a maximum sentence of 10 years imprisonment and a fine. 4 POLICY EFFECT The Trust is committed to the public service values of integrity, accountability and openness. The Trust is also committed to raise awareness and enforce the message that fraud, bribery and corruption within the NHS is not acceptable and will not be tolerated. The Trust will: ensure that strategic governance arrangements in respect of anti-fraud, bribery and corruption measures are in place. inform and involve those who work for or use the NHS about fraud and how to tackle it. prevent and deter fraud in the NHS taking away the opportunity for fraud to re-occur and discourage those individuals who may be tempted to commit fraud. hold to account those who have committed fraud against the NHS by detecting and prosecuting offenders and seeking redress where viable. The Trust will adopt a triple tracking approach when conducting fraud, bribery and corruption investigations with the following options available: Disciplinary action taken by the Trust including referral to Professional Regulatory body where appropriate. Criminal prosecution. Civil action to recover money defrauded, including investigation costs and interest. The nature and level of sanction will depend on the specific circumstances of each case. Any genuine concerns / suspicions about fraud, bribery and corruption should be reported (see Appendix A). The Trust will not tolerate the harassment or victimisation of anyone raising a genuine concern and will consider it a disciplinary matter to victimise anyone who has raised such a concern. 5 ROLES AND RESPONSIBILITIES In accordance with the NHS Standard Contract, the Trust must put in place and maintain appropriate anti-fraud, bribery and corruption arrangements. 5

Agenda Item 14.4 Chief Executive The Chief Executive has the overall responsibility for funds entrusted to the organisation as the Accountable Officer. The Chief Executive must ensure adequate policies and procedures are in place to protect the organisation and the public funds entrusted to it. Director of Finance The Director of Finance, as a member of the Board, is responsible for overseeing and providing strategic management and support for all work to tackle fraud, bribery and corruption within the Trust. Local Counter Fraud Specialists (LCFSs) The LCFSs will work with key colleagues and stakeholders to ensure that the Trust meets NHS Protect s Standards for Providers: Fraud, Bribery and Corruption. The LCFSs are accountable to the Director of Finance and report on the progress of all anti-fraud, bribery and corruption activity to the Trust s Audit Committee. Internal and External Audit Internal and External Audit play a key role in reviewing controls, identifying system weaknesses and ensuring compliance with the Standing Orders and Standing Financial Instructions. Any incident / suspicions of fraud, bribery or corruption that comes to Internal or External Audit s attention will be passed immediately to the LCFSs. The outcome of investigations may necessitate further work by audit to review systems and procedures. Human Resources Human Resources will liaise with managers and the LCFSs from the outset if an employee is suspected of being involved in fraud, bribery or corruption, in accordance with agreed protocols. Management, advised by Human Resources, are responsible for taking forward disciplinary proceedings against employees who have committed an offence. Close liaison between the LCFSs and Human Resources will be essential to ensure that any parallel sanctions (i.e. criminal, civil and disciplinary sanctions) are applied effectively and in a coordinated manner. Managers All managers are responsible for ensuring policies and procedures within their work areas are adhered to and kept under review. Managers should ensure that staff within their teams are aware of fraud, bribery and corruption risks and understand the importance of protecting the Trust against them. Managers may also be responsible for the enforcement of disciplinary action for employees who do not comply with policies and procedures. If a manager suspects, or is made aware of, suspicions of fraud, bribery and corruption they must report it. (See Appendix A) 6

Agenda Item 14.4 Employees All employees should carry out their duties with due regard for the Trust s policies and procedures, be aware of fraud, bribery and corruption risks and understand the importance of protecting the Trust against them. All employees must report any concerns / suspicions of fraud, bribery or corruption. (See Appendix A) NHS Protect NHS Protect provides national leadership for NHS anti-crime work and is the body responsible for delivering the anti-fraud and pro-security functions that cannot be undertaken locally. NHS Protect Area Anti-Fraud Specialists (AAFSs) AAFSs are the operational link between NHS Protect and the Trust. They use their skills and knowledge to provide support, advice and guidance to NHS bodies in the region they are responsible for. 6 EQUALITY ANALYSIS This Policy has been assessed for its impact upon equality. The Equality Analysis can be seen in Annex 1. The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. Potentially protected groups could be affected by this policy, however, there is currently no evidence to support this and whether or not it would be negative. Data will be collected and monitored to identify and address any disproportionate negative impact on protected groups via pertinent HR policies, including Conduct and Discipline, Dignity at Work and Whistleblowing. 7 CONSULTATION AND REVIEW PROCESS Relevant staff have been involved / consulted on the development of this policy. 8 STANDARDS / KEY PERFORMANCE INDICATORS The Trust must comply with NHS Protect s Standards for Providers: Fraud, Bribery and Corruption. 9 MONITORING COMPLIANCE AND EFFECTIVENESS The effectiveness of this policy will be monitored by the LCFSs by assessment against the Standards for Providers: Fraud, Bribery and Corruption. An annual return and report will be completed by the LCFSs to demonstrate how successful 7

Agenda Item 14.4 the Trust has been in complying with the standards. This report will form part of a qualitative assurance process in respect of the Trust s anti-crime arrangements. Equality Analysis will identify any disproportionate adverse effects on particular staff groups. 8

Agenda Item 14.4 Policy element to be monitored Standards/ Performance indicators Process for monitoring Individual or group responsible for monitoring Frequency or monitoring Responsible individual or group for development of action plan Responsible group for review of assurance reports and oversight of action plan Whole Policy NHS Protect s Standards for Providers: Fraud Bribery and Corruption. Self review of compliance against the required standards supported by a report with statement of assurance. Trust LCFSs Yearly Trust LCFSs NHS Protect Audit Committee Monitoring Protected Characteristics by Equality treatment of ESR data Deputy Director of HR Annually Director of HR with HR Senior Team Workforce Committee 9

Agenda Item 14.4 10 REFERENCES / ASSOCIATED DOCUMENTATION Legislation Fraud Act 2006 Bribery Act 2010 NHS Guidance NHS Protect's Standards for Providers: Fraud, Bribery and Corruption Trust Policies (All can be found on the Trust Policy Hub) Whistleblowing Standards of Business Conduct Standing Orders Standing Financial Instructions 10

Appendix A Reporting Fraud, Bribery and Corruption in the NHS Any genuine concerns / suspicions about fraud, bribery and corruption should be reported directly to the Trust s LCFSs who are based within the Internal Audit Department and can be contacted in the following ways: By Post By Telephone By Fax By E-mail Internal Audit External: 1 st Floor, Trust Headquarters St. James s Hospital Leeds (0113) 2066329 Internal: Ext. 66329 (0113) 2066784 richard.schmidt@nhs.net lina.anderson@nhs.net LS9 7TF If it is felt, for any reason, that the matter cannot be reported internally, concerns / suspicions can be reported to the: NHS Fraud & Corruption Reporting Line on 0800 028 40 60 or NHS Fraud & Corruption reporting website at www.reportnhsfraud.nhs.uk 11

Annex 1 - Equality Analysis A screening process can help judge relevance and provides a record of both the process and decision. Screening should be a short exercise that determines relevance for all new and revised strategies, policies, services and functions. Completed at the earliest opportunity it will help to determine: the relevance of proposals and decisions to equality, and whether or not it is necessary to carry out a full equality analysis Division/Programme: Finance Lead person(s): Richard Schmidt / Lina Anderson (LCFSs) Service area/project: Internal Audit Date: July 2014 1. Title: Anti-Fraud, Bribery and Corruption Policy Is this a: <Tick as appropriate> Change to an existing Strategy / Policy x New Strategy/policy Change to Service(s) / Function (s) Other If other, please specify: 2. Summary of the strategy, policy, Service(s) for function(s) being assessed: The Trust is committed to the public service values of integrity, accountability and openness. The Trust is also committed to raise awareness and enforce the message that fraud, bribery and corruption within the NHS is not acceptable and will not be tolerated This policy sets out the Trust s commitment to reducing the level of fraud, bribery and corruption within both the Trust and the wider NHS to an absolute minimum, keeping it at that level and freeing up public resources for better patient care. 12

3. Relevance to equality All the Trusts policies, projects, strategies, services and major developments affect patients, carers, service users, employees or the wider community. These will also have a greater or lesser relevance to equality and diversity. The following questions will help you to identify how relevant your proposals are. When considering these questions think about age, carers, disability, gender reassignment, race, religion or belief, sex, sexual orientation, pregnancy and maternity and any other relevant characteristics (for example socio-economic status, social class, income, unemployment, residential location or family background and education or skills levels). Questions No Is there any indication or evidence (including from consultation with relevant groups) that different groups have different needs, experiences, issues and priorities in relation to the proposed policy or proposal? X Is there potential for or evidence that the proposed policy or proposal will affect different population groups differently (including possibly discriminating against certain groups)? X Have there been or are there likely to be any public concerns (including media, academic, voluntary or sector specific interest) about the policy or proposal? X Could the proposal affect how our services, commissioning or procurement activities are organised, provided, located and by whom? X Could the proposal affect our workforce or employment practices? X Is there potential for or evidence that the proposed policy or proposal will not promote equality of opportunity or promote good relations between different groups? X 13

If you have answered no to the questions above please complete section 6 If you have answered yes to one or more of the above and; Believe that the policy or proposal is equality relevant, please complete section 5 and carry out a full Equality Analysis Believe you have already considered the impact of your proposal on equality and diversity and there is little or no relevance, please go to section 4 Believe that whilst the policy or proposal is equality relevant, a full Equality Analysis is not necessary at this stage, please go to section 4 4. Considering the impact on equality and diversity If you have answered yes to one or more of the screening questions and believe that the policy or proposal is not equality relevant or that a full equality analysis is not required at this stage, please provide specific details for all three areas below: How have you considered equality and diversity? (think about the scope of the proposal, who is likely to be affected, equality related information, gaps in information and plans to address, consultation and engagement activities (taken place or planned) with those likely to be affected) Key findings (think about any potential positive and negative impact on the different protected characteristics, potential to promote strong and positive relationships between groups, potential to bring groups/communities into increased contact with each other, perception that the proposal could benefit one group at the expense of another) Actions Potentially protected groups could be affected by this policy, however, there is currently no evidence to support this and whether or not it would be negative. Data will be collected and monitored to identify and address any disproportionate negative impact on protected groups via pertinent HR policies, including Conduct and Discipline, Dignity at Work and Whistleblowing. 14

5. If the policy or proposal is equality relevant, you will need to carry out a full Equality Analysis Date to scope and plan your equality analysis: Date to complete your equality analysis: Lead person for your equality analysis: (Include name and job title) <Name> <Job Title> 6. Governance, ownership and approval Please state here who has approved the actions and outcomes of the screening Name Job title Date David Gregory Head of Internal Audit July 2014 15

For use by the Equality Analysis sub-group 1. Governance, ownership and approval State here which members of the Equality Analysis sub-group have approved the actions and outcomes from the equality analysis relevance screening. Name Job Title Date 2. Publishing This screening document will act as evidence that due regard to equality and diversity has been given. If you are not carrying out a full equality analysis the screening document will need to be published. Please send a copy to the Equality Team for publishing. Date screening completed Date received by Equality Team Date published If the screening relates to a non MfS change, please send the screening template to the Equality Analysis sub-group via Elizabeth Alarcon-Rhodes at Elizabeth.Alarcon- Rhodes@leedsth.nhs.uk 16

Annex 2 - Plans for Communication and Dissemination of Policy This plan for communication and dissemination of the policy must be completed for all policies, and attached to the policy before being submitted to the Trust Board (or Committee of the Board) for approval. Title of document: Approving Group / Committee Date Approved: Anti-Fraud, Bribery and Corruption Policy Trust Board TBC Target Audience Eg staff groups or stakeholders Objective Action Person Responsible Target date All Staff To raise awareness and understanding Publicise in Intouch bulletin LCFSs Within 1 month of approval All Staff To raise awareness and understanding Utilise existing fraud awareness materials / activities: LCFSs On-going - Induction material (coasters) - Posters / leaflets - Payslip attachment - Counter fraud websites All Staff To raise awareness and understanding Cross reference from other Trust policies: Whistleblowing LCFSs On-going Standards of Business Conduct 17

Annex 3 - Checklist for the Review and Approval of Policy To be completed and attached to the policy when submitted to the appropriate committee for consideration and approval. Title of document being reviewed: 1. Title and Rationale Is the title clear and unambiguous? Is this the most appropriate document type? eg if it is a policy, does it set out requirements that need to be binding? 2. Development Process Has a reasonable attempt has been made to ensure relevant expertise has been used? Has there been appropriate consultation with stakeholders and users? 3. Content Is the purpose of the document clear? Is the staff summary clear and adequate? Are the intended outcomes clearly described? (the Policy Effect) Is there a Definitions section giving an explanation of key terms used. Is the content sufficiently concise and straightforward to be clear? Can any detail or complex material be transferred to an appendix? Is there a ratified Equality Analysis 4. Evidence Base Is the evidence to support the document identified and key references cited? 5. Approval Does the document identify which committee / group has ensured it is appropriate prior to submission for formal approval? If appropriate has the TCNC approved the document? 6. Dissemination and Implementation /No/ Unsure N/A Comments 18

Title of document being reviewed: Is there a communications plan to identify how this will be done? Does the implementation plan include the necessary training / support to ensure compliance? 7. Process to Monitor Compliance and Effectiveness Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document? Is there a plan to monitor compliance with the document? 8. Review Date Is the review date acceptable? 9. Overall Responsibility for the Document Is it clear who will be responsible for coordinating the dissemination, implementation and review of the document? /No/ Unsure Comments Committee Approval (This section only required for staff- related policies) If the committee is happy to approve this document, please sign and date it and forward copies to the person with responsibility for disseminating and implementing the document and the person who is responsible for maintaining the organisation s database of approved documents. Name Signature Date Name Signature Date 19

Annex 4 - Version Control Sheet This document to be maintained by the Policy/Procedure/Protocol Lead, and a copy attached to each version as it is circulated for consultation/input. Version Date Author Status Comment (including actions taken) 20