MIAA Anti-Fraud Services Annual Report 2015/2016 Audit Committee () NHS Blackpool Clinical Commissioning Group
Contents 1. Introduction 2. Executive Summary 3. Standards for Commissioners 4. Summary of Work Completed 5. Referral Summary Appendix A- Contract Performance Appendix B- Self Assessment against the NHS Protect Standards for Commissioners P a g e 2
1. Introduction The Anti-Fraud Annual Report offers the Audit Committee the opportunity to review in totality the work completed by the CCG s Anti-Fraud Specialist (AFS) during the period April 2015 to March 2016. The ultimate aim of all anti-fraud work is to support improved NHS services and ensure that fraud within the NHS is clearly seen as being unacceptable. Stopping the theft of public money by fraudsters who are committing criminal offences brings with it the bonus of being able to see NHS funds being deployed for the public good, as the taxpayer intended. 2. Executive Summary During the financial year 2015/16 the AFS has completed a wide range of work across the main key areas of activity as outlined by NHS Protect and agreed within the workplan by the Audit Committee. The plan has been delivered in full with no changes to the agreed original plan. A limited number of fraud investigations have been undertaken. For the following has been achieved during the year: The AFS has had regular meetings and liaison with the Chief Finance Officer to discuss the progress being made in delivering the agreed anti-fraud work plan. The AFS delivered a fraud awareness event to local Practice Managers and has responded to a number of queries, during the year, on patient registration; The AFS has provided support in the development of the CCG s personal health budget arrangements. Information has been shared with local authority staff as to what potentially could be considered to be fraudulent activity in this area; Regular liaison has taken place with Internal Audit to ensure a joined up approach; An updated Fraud, Bribery and Corruption Policy was completed and approved by the Audit Committee. The AFS conducted a review of the whistleblowing policy and attended a meeting of the Senior Managers team to debate and discuss the proposed changes. The AFS completed and submitted to NHS Protect an initial assessment of the CCGS compliance with the new standards for commissioners in July 2015. A P a g e 3
gap analysis report was submitted to the CCG s Audit Committee indicating those standards where the CCG had or could not achieve full compliance; Two anti-fraud newsletters were issued to the CCG highlighting current fraud issues and providing information on successful prosecution cases; Two Anti-Fraud message were included within staff payslips in June and August 2015; A series of fraud alerts, briefings and guidance has been issued to the CCG during the year; A proactive review of conflicts of interest has been completed. The findings will be reported in the next progress report to the Audit Committee; Progress has been made in reviewing the National Fraud Initiative (NFI) payroll data matches; Three fraud referrals have been investigated during the year; During the year three fraud investigations have been undertaken with one remaining in progress at year end. Section 4 of the Annual Report highlights the main areas of activity undertaken during the financial year, much of this activity has been reported to the committee in year via the regular anti-fraud progress reports. The work undertaken in this and previous years at the CCG supports the embedding of a strong anti-fraud / anti-crime culture within the organisation. The AFS would like to acknowledge the continued support received from the CFO, Audit Committee and all staff in the conduct anti-fraud activity at the CCG. 3. Standards for Commissioners: NHS Protect require that commissioners should ensure that NHS resources are protected from fraud, bribery or corruption. To this end NHS Protect have developed a range of standards for commissioners to ensure that appropriate measures to tackle fraud, bribery and corruption are put in place. It is the responsibility of the organisation as a whole to ensure it meets the required standards. However, one or more departments or individuals may be responsible for implementing a specific standard. The CCG is required to comply with all the Standards for Commissioners issued NHS Protect. There is an NHS Protect quality assurance process for commissioners. The process includes a requirement for an annual declaration to be made to NHS Protect by the P a g e 4
CCG based upon the perceived level of compliance with the standards. Following this submission NHS Protect will conduct, on a risk basis, a percentage of validation checks and themed assessments relating to national priorities. Set out below are details of the CCG s views on the current level of compliance with the standards. This disclosure will form the basis of the submission to be made to NHS Protect. Self Assessment Against the Standards Hold to Account Prevent & Deter Inform & Involve Strategic Governance 0 1 2 3 4 5 6 7 8 9 Neutral Red Amber Green Amber and Red Standards The following standards have been assessed as currently having a red or amber level of compliance against the standards. The rationale for this assessment and corrective action, where applicable is set out in the table below: Area Ref Standard Comment Strategic Governance 1.8 The organisation reviews the anti-fraud, bribery and corruption arrangements in place within the providers it contracts to deliver NHS services, to ensure they comply with the conditions set out in Service Condition In order to effectively risk assess the anti-fraud arrangements at provider organisations the CCG requires access to the self-review tool information submitted to NHS Protect by all provider organisations. As yet the CCG has not been provided with any information from P a g e 5
Area Ref Standard Comment 24 of the NHS Standard Contract. NHS Protect from which to conduct a risk based assessment. Strategic Governance 1.9 The organisation ensures that the providers it contracts to deliver NHS services under the NHS Standard Contract implement any recommendations made by the commissioner itself or by NHS Protect following a quality assessment of antifraud, bribery and corruption arrangements. NHS Protect will provide a written report to the organisation, including any recommendations. The CCG does not consider it appropriate or reasonable to request information from providers which has already been submitted to NHS Protect. The CCG has not received any inspection reports from NHS Protect during the year for any organisation for which the CCG is the lead commissioner. The CCG will review the findings of each report received from NHS Protect to consider the level of fraud risk arising from their recommendations and to decide what action, if any, is required by the CCG. Inform Involve & 2.4 The organisation has a code of conduct that includes reference to fraud, bribery and corruption and the requirements of the Bribery Act 2010. Staff awareness of the requirements of the code of conduct is regularly tested. The code of conduct will be reviewed during 2016-17 to ensure that its content meets NHS Protect requirements. The AFS will work with the CCG to ensure that awareness of the document is measured across CCG staff. Hold Account to 4.4 The organisation shows a commitment to pursuing, and/or supporting NHS Protect in pursuing, the full range of available sanctions (criminal, civil and disciplinary) against those found to have committed fraud, bribery or corruption, as detailed in NHS Protect s guidance and following the advice of area antifraud specialists. Blackpool CCG is committed to pursuing a full range of sanctions. In accordance with the NHS Protect assessment criteria, the fact that the CCG has not received any fraud referrals which have warranted consideration of sanctions means that full compliance with this standard cannot be evidenced. P a g e 6
Area Ref Standard Comment Hold Account to 4.7 The organisation seeks to recover, and/or supports NHS Protect in seeking to recover, NHS funds that have been lost or diverted through fraud, bribery and corruption, following an assessment of the likelihood and financial viability of recovery. The organisation publicises cases that have led to successful recovery of NHS funds. Blackpool CCG is committed to the recovery of NHS funds lost due to fraud, bribery or corruption. In accordance with the NHS Protect assessment criteria, the fact that the CCG has not received any fraud referrals in 2015-16 means that full compliance with this standard cannot be evidenced. P a g e 7
4. Summary of Work Completed This section of the report details the work completed against each of the four generic areas of anti-fraud activity as set out by NHS Protect. Strategic Governance The CCG ensures that Anti-Crime measures are embedded at all levels across the organisation. Activity Outcomes The AFS met with the CFO throughout the year to discuss progress against the plan and to consider any guidance issued by NHS Protect. The AFS has attended three Audit Committee meetings as agreed throughout the year. The AFS prepared and delivered the Annual Anti-Fraud Workplan 2015/16 and Annual Anti-Fraud Report 2014/15 to the Audit Committee. The AFS has attended: o Witness statement training with NHS Protect on the 1st July 2015. o Whistleblowing training with The Public Concerns at Work on the 18th September 2015. o The AFS has attended the NHS Protect Forum Meeting on the 24 th November 2015. The meeting scheduled for 1st July 2015 was cancelled by the Area Anti-Fraud Specialist. The AFS in liaison with the CCG completed the SRT, the CCG s overall rating was GREEN and was submitted to NHS Protect by the 31/07/2015. An Action plan was developed in liaison with the CCG and submitted to the Audit Committee in 04/09/2015. The AFS undertook a detailed fraud risk assessment to identify potential or actual risks of fraud, bribery and corruption. The results together with To ensure the CFO is appraised as to the progress of the Anti-Fraud Workplan. To provide assurance to the Audit Committee that progress is being made against the agreed Annual Anti-Fraud Workplan. A programme of work is developed that seeks to address potential fraud risk areas. To be updated on changes to national and local fraud, bribery and corruption issues as well as providing the opportunity to share best practice and undertake training. To ensure the CCG s compliance with NHS Protect Standards for Commissioners in accordance with their requirements. To ensure that the CCG and the AFS are aware of all apparent and emerging risks relating to fraud, bribery and corruption. P a g e 8
the key priorities identified by NHS Protect have been taken into account in developing the Anti-Fraud Annual Workplan 2016/17. The AFS and IA have a programme in place to discuss progress against the respective workplans and any issues arising from the respective work. To ensure that all parties are aware of the fraud, bribery and corruption risks and progressed effectively. Inform & Involve The CCG raises awareness of crime risks against the NHS, and works with NHS staff and the public to publicise the risks and effects of crime against the NHS. Activity Outcomes Fraud awareness training was provided to the local Practice Manager. This training covered fraud risks related to GP practice activity as well as covering the reporting arrangements for concerns relating to fraud. The CCG has ongoing work to raise awareness of fraud and corruption and create an anti-fraud and corruption culture amongst all staff using all available media. Anti-Fraud, Bribery and Corruption Policy The AFS updated the existing policy in line with NHS Protect guidance and included changes in respect of the sequence in the Roles and Responsibility section. The overarching message and purpose of the policy has not changed. Anti-Fraud Newsletters The AFS issued the Summer 2015 edition of the Sentinel Newsletter to the CCG on the 02/09/2015. The Newsletter focussed on: o Fraud and the NHS o NHS Charging Regulations for overseas visitors o Raising Concerns at Work Whistleblowing o Outcomes of NHS Fraud Cases o Phishing Emails o Protect yourself from Fraud o Contact details for the AFS. To ensure compliance against good practice and NHS Protect requirements and to ensure all staff are aware of the policy. To raise awareness and inform the CCG of any developing and emerging trends relating to fraud, bribery and corruption so that informed decisions can be made to minimise the risks. P a g e 9
The AFS issued the Winter 2015 edition of the Sentinel Newsletter to the CCG on the 22/12/2015. The Newsletter focussed on: o Gifts and Hospitality o Outcomes of Recent NHS Fraud Cases o Fraud Scams o Cyber Crime o Festive Frauds o Contact Details for the AFS Anti-Fraud, Bribery and Corruption web area on the CCG s Intranet: The AFS has requested that all Alerts, Newsletters, Articles and Anti-Fraud, Bribery and Corruption Policy be uploaded. The organisation has a clear communications plan that sets out how information will be publicised to raise awareness and inform of the consequences. Prevent & Deter The CCG discourages individual who may be tempted to commit crime against the NHS and ensures that opportunities for crime to occur are minimised. The organisation proactively detects fraud in identified risk areas. Activity Anti-Fraud Alerts, Bulletins, Notices, Briefings and NHS Protect Bulletins. The AFS has issued the following documentation to the CCG: Outcomes The CCG remains vigilant and fully appraised of developing and emerging trends so that appropriate action can be taken by the CCG to prevent and deter. Standards for Commissioners Briefing Note NHS Protect Taxonomy Report (Intelligence Report Update 2014/15) Information re the Launch of the Revised Online Reporting Toolkit Payroll Fraud Factsheets Alert 1 - Private Branch Exchange (PBX) telephone lines hacked for premium rate numbers Alert 2 - Conference Cancellation Fees Alert 3 - Bogus Emails re Invoice containing Dridex Malware Software NHS Protect Intelligence Bulletin re Mandate Fraud. P a g e 10
Review Policies/Protocols/Procedures to Design out the risks of Fraud, Bribery and Corruption: Whistleblowing Policy o The AFS provided recommendations to strengthen the current policy. National Fraud Initiative (NFI) Payroll Matches o The payroll matches have been reviewed and all cleared with no issues. The AFS completed the outcomes validation declaration within the timescales set by the NFI. The AFS has provided the CCG with one invoice self-assessment checklist, this has been completed and returned to the AFS. The checklist is to support the CCG s compliance with NHS Protect Standards. To ensure that the CCG has robust policies, procedures and protocols in place that include reference to fraud, bribery and corruption to prevent and deter any fraudulent activities and any changes are communicated appropriately. To provide a platform for the CCG to review payroll information which is risk assessed and cross referenced against 3rd party health bodies, increasing the CCG s facility to identify areas of concern or possible fraudulent activities. The CCG is aware of specific risks pertaining to invoice fraud and appropriate measures can be taken and are in place to prevent this from happening. Hold to Account All suspicions of fraud are investigated in a timely and professional manner and all appropriate sanctions and redress actions are applied. Activity Initial fact-finding in respect of received referrals. Outcomes All queries are handled in accordance with NHS Protect guidance. All matters requiring enquiries to be made will be logged on FIRST. During the financial year the AFS has received three referrals which have required investigation. All relevant information has been input onto FIRST in line with NHS Protect guidance. FIRST used to record all system weaknesses identified as a result of investigations and/or proactive prevention and detention exercise. Compliance with NHS Protect investigation requirements. System weaknesses and outcomes from fraud prevention are recorded in accordance with NHS Protect s FIRST requirements and Standards for Commissioners. All investigations are logged on FIRST. The system is used to record the progress of an investigation to its conclusion. P a g e 11
The AFS has recorded all referrals on FIRST and ensures each case is updated regularly with progress made to date. 5. Referral Summary Best practice requires that The organisation ensures that FIRST is used to record all allegations of suspected fraud, bribery and corruption and to provide information to inform national intelligence. The tables below summarise both the investigation and intelligence activity that has been logged on FIRST during the current year. Activity Current Period Referrals Received in Year 3 Referrals Closed In Year 2 Referrals Open at Year End 1 Summary of Referrals Ref Allegation Received Status Outcomes INFO#71968 False Representation 13/09/15 Closed No trace of subject working for the CCG INFO#73064 Abuse of Position 06/01/16 Closed Not a fraud issue NWRT-16-00012 Abuse of Position 14/03/16 Open Investigation in Progress P a g e 12
Appendix A: Contract Performance The position against the planned days is provided in the table below which represents the actual time expended in the delivery of your anti-fraud service. Any amendments to the original plan will have been reported to the Committee and discussed with the Chief Finance Officer for approval and highlighted separately to further facilitate the monitoring process. Proactive Activity Agreed Days Actual Days Core Workplan 25 25 Reactive Day Authority Agreed Days Actual Days N/A 0 0 Total Reactive Days 0 0 General Performance Indicators The following provides some general performance indicator information to support the Committee in assessing the performance of MIAA s Anti-Fraud Service. Element Status Summary Progress against plan Green AFS has delivered all aspects of the plan as agreed. Time charged against plan Timeliness Qualified Staff Compliance with NHS Protect Standards for Commissioners Use of FIRST Green Green Green Green Green The plan has been delivered within the number of agreed days. There were no significant delays in the delivery of the workplan. The nominated AFS has been accredited through NHS Protect and has undertaken CPD The CCG has assessed itself as an overall GREEN rating against the NHS Protect Standards for Commissioners. The AFS has utilised FIRST to record progress made in addressing all fraud referrals received by the CCG. A p p e n d i x A 1
Appendix B- Self Assessment against the NHS Protect Standards for Commissioners Strategic Governance Ref Standard RAG 1.1 A member of the executive board is responsible for overseeing and providing strategic management and support for all anti-fraud, bribery and corruption work within the organisation. 1.2 The organisation s non-executive directors and board level senior management provide clear and demonstrable support and strategic direction for anti-fraud, bribery and corruption work. Evidence of proactive management, control and evaluation of anti-fraud, bribery and corruption work is present. 1.3 The organisation employs or contracts in a qualified person (or persons) to undertake the full range of anti-fraud, bribery and corruption work, including proactive work to prevent and deter fraud, bribery and corruption and reactive work to hold those who commit fraud, bribery or corruption to account. 1.4 The organisation has carried out risk assessment activity to identify fraud, bribery and corruption risks and has anti-fraud, bribery and corruption provision that is proportionate to the level of risk identified. Measures to mitigate identified risks are included in an organisational work plan, progress is monitored at a senior level within the organisation and results are fed back to the audit committee. 1.5 The organisation reports annually on how it has met the standards set by NHS Protect in relation to antifraud, bribery and corruption work, and details corrective action where standards have not been met. 1.6 The organisation ensures that those carrying out anti-fraud, bribery and corruption work have all the necessary support to enable them to carry out their role efficiently, effectively and promptly. This includes (but is not limited to) access to IT systems, access to secure storage, and access to key managers, staff groups and the audit committee. 1.7 The organisation ensures that there are effective lines of communication between those responsible for anti-fraud, bribery and corruption work and other key staff groups within the organisation, including (but not limited to) audit, risk, finance, communications and human resources. There is evidence of positive outcomes as a result of this liaison. 1.8 The organisation reviews the anti-fraud, bribery and corruption arrangements in place within the providers it contracts to deliver NHS services, to ensure they comply with the conditions set out in Service Condition 24 of the NHS Standard Contract. Where necessary, the organisation recommends corrective action and follows it up to ensure it has been implemented. NHS Protect will give assurance to the organisation that the provider is complying with the anti-fraud, bribery and A p p e n d i x B 1
Ref Standard RAG corruption requirements set out in the NHS Standard Contract, following quality assurance and/or assessment. 1.9 The organisation ensures that the providers it contracts to deliver NHS services under the NHS Standard Contract implement any recommendations made by the commissioner itself or by NHS Protect following a quality assessment of anti-fraud, bribery and corruption arrangements. NHS Protect will provide a written report to the organisation, including any recommendations. 1.12 The organisation has appropriate contract monitoring arrangements in place for all commissioned primary and secondary healthcare services, including acute, GP, pharmaceutical, dental and ophthalmic services. NB standards 1.11 & 1.12 relate to NHS England and as such require no self-assessment by the CCG Inform & Involve Ref Standard RAG 21 The organisation has an ongoing programme of work to raise awareness of fraud, bribery and corruption and to create an anti-fraud, bribery and corruption culture among all staff, across all sites, using all available media. This should cover NHS Protect s Fraud and Corruption Reporting Line and online fraud reporting tool, and the role of the accredited counter fraud specialist. Content may be delivered through presentations, newsletters, leaflets, posters, intranet pages, induction materials for new staff emails and other media, making use of NHS Protect s crime awareness toolkit as appropriate. The effectiveness of the awareness programme is measured. 2.2 The organisation has an anti-fraud, bribery and corruption policy that follows NHS Protect s strategy and 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 2.3 The organisation liaises proactively with other organisations and agencies (including local police, the Home Office, local authorities, regulatory and professional bodies) to assist in countering fraud, bribery and corruption. All liaison complies with relevant legislation, such as the Data Protection Act 1998, and with relevant organisational policies. The organisation can demonstrate improved investigative and operational effectiveness as a result of the liaison. 2.4 The organisation has a code of conduct that includes reference to fraud, bribery and corruption and the requirements of the Bribery Act 2010. Staff awareness of the requirements of the code of conduct is regularly tested. A p p e n d i x B 2
Prevent & Deter Ref Standard RAG 3.1 3.1 The organisation reviews new and existing relevant policies and procedures, using audit reports, investigation closure reports and NHS Protect guidance, to ensure that appropriate anti-fraud, bribery and corruption measures are included. This includes (but is not limited to) policies and procedures in human resources, standing orders, standing financial instructions and other finance policies. The organisation evaluates the success of the measures in reducing fraud, bribery and corruption, where risks have been identified. 3.2 The organisation uses all available information and intelligence to identify anomalies that may be indicative of fraud, bribery and corruption and takes the appropriate action to address them. Relevant information and intelligence may include (but is not limited to) internal and external audit reports, information on outliers, recommendations in investigation reports and information from payroll. The findings are acted upon promptly. 3.3 The organisation issues, implements and complies with all appropriate fraud, bribery and corruption intelligence bulletins, prevention guidance and alerts issued by NHS Protect. In addition, the organisation issues local anti-fraud, bribery and corruption warnings and alerts to all relevant staff following guidance in NHS Protect s Intelligence Alerts, Bulletins and Local Warnings Guidance. The organisation has an established system of follow up reviews to ensure that it remains vigilant and that all appropriate action has been taken. 3.4 The organisation ensures that all new staff are subject to the appropriate level of pre-employment checks, as recommended by NHS Employers, before commencing employment within the organisation. Assurance is sought from any employment agencies used that the staff they provide have been subject to adequate vetting checks, in line with guidance from NHS Protect and NHS Employers. 3.5 The organisation has proportionate processes in place for preventing, deterring and detecting fraud and corruption in procurement. 3.6 The organisation has proportionate processes in place for preventing, deterring and detecting invoice fraud, bribery and corruption, including reconciliation, segregation of duties, processes for changing supplier bank details and checking of deliveries Hold to Account Ref Standard RAG 4.1 4.1 The organisation ensures that FIRST is used to record all reports of suspected fraud, bribery and corruption, to inform national intelligence. FIRST is also used to record all system weaknesses identified as a result of investigations and/or proactive prevention and detection exercises. A p p e n d i x B 3
Ref Standard RAG 4.2 The organisation uses FIRST to support and progress the investigation of fraud, bribery and corruption allegations, in line with NHS Protect guidance. 4.3 The organisation supports the investigation of all allegations of fraud, bribery and corruption, and ensures that all the requirements of relevant legislation, as set out in NHS Protect s Investigation Case File Toolkit and the NHS Anti-fraud manual, are adhered to. 4.4 The organisation shows a commitment to pursuing, and/or supporting NHS Protect in pursuing, the full range of available sanctions (criminal, civil and disciplinary) against those found to have committed fraud, bribery or corruption, as detailed in NHS Protect s guidance and following the advice of area antifraud specialists. 4.5 The organisation completes witness statements that follow best practice and comply with national guidelines/ 4.6 Interviews under caution are conducted in line with the National Occupational Standards (CJ201.2) and the Police and Criminal Evidence Act 1984. 4.7 The organisation seeks to recover, and/or supports NHS Protect in seeking to recover, NHS funds that have been lost or diverted through fraud, bribery and corruption, following an assessment of the likelihood and financial viability of recovery. The organisation publicises cases that have led to successful recovery of NHS funds. A p p e n d i x B 4