NHS Requirement 1A:

A member of the executive board or equivalent body is accountable for provision of strategic management of all counter fraud, bribery and corruption work within the organisation. The accountable board member is responsible for the provision of assurance to the executive board in relation to the quality and effectiveness of all counter fraud bribery and corruption work undertaken.

The accountable board member is responsible for ensuring that nominations to the NHSCFA for the accountable board member, audit committee chair and counter fraud champion are accurate and that any changes are notified to the NHSCFA at the earliest opportunity and in accordance with the nominations process.

N.B. 'Equivalent body' may include, but is not limited to, the board of directors, the board of trustees or the governing body. Oversight of counter fraud, bribery and corruption work should not be delegated to an individual below this level of seniority in the organisation.

Organisation meets the requirement

There is a member of the executive board or equivalent body who has a clearly defined responsibility for the strategic management of, and support for, counter fraud, bribery and corruption work.

There is evidence that this responsibility is discharged effectively. Counter fraud, bribery and corruption objectives are discussed and reviewed at a strategic level within the organisation and this is documented.

The member of the executive board or equivalent body has ensured the provision of relevant and timely information regarding counter fraud, bribery and corruption work to the coordinating commissioner upon request.

Where additional or corrective action is necessary, this is discussed and the appropriate actions taken and documented.

The accountable board member has ensured that nominations to the NHSCFA for the accountable board member, audit committee chair and counter fraud champion are accurate.

The accountable board member has notified any / all changes to nominations to the NHSCFA as soon as reasonably practicable.

Organisation partially meets the requirement

Not applicable to this requirement.

Organisation does not meet the requirement

There is no member of the executive board, or equivalent body, who has a clearly defined responsibility for the strategic management of, and support for, counter fraud, bribery and corruption work.

Where such a responsibility is defined, there is little or no evidence of strategic management of, or support for, counter fraud, bribery and corruption work.

The member of the executive board or equivalent body has not ensured the provision of relevant and timely information regarding counter fraud, bribery and corruption work to the coordinating commissioner upon request.

The accountable board member responsible has not ensured that nominations to the NHSCFA for the accountable board member, audit committee chair and counter fraud champion are accurate.

Guidance, supporting documentation and evidence

Organisations should consider the following (the list is not exhaustive):

  • Board meeting minutes
  • Organisational counter fraud, bribery and corruption work plan
  • Annual report on counter fraud, bribery and corruption work
  • Progress reports to the audit committee, board or executive level managers
  • Minutes of relevant meetings, action points and records of their execution
  • Audit committee minutes
  • Standing Orders/Standing Financial Instructions
  • Evidence of the supply of counter fraud, bribery and corruption information to coordinating commissioners. This may include, but is not limited to, the functional standard return, the annual report of counter fraud work and the counter fraud work plan.
  • NHSCFA benchmarking data
  • Documentation from the nominations process

NHS Requirement 1B:

The organisation’s non-executive directors, counter fraud champion or lay members and board/governing body level senior management are accountable for gaining assurance that sufficient control and management mechanisms in relation to counter fraud, bribery and corruption are present within the organisation.

The counter fraud champion understands the threat posed and promotes awareness of fraud, bribery and corruption within the organisation.

Board level evaluation of the effectiveness of counter fraud, bribery and corruption work undertaken is documented. Where recommendations have been made by NHSCFA following an engagement, it is the responsibility of the accountable board member to provide assurance to the board surrounding the progress of their implementation.

The organisation reports annually on how it has met the requirements set by NHSCFA in relation to counter fraud, bribery and corruption work, and details corrective action where requirements have not been met.

Organisation meets the requirement

Senior management ensures that recommended actions are implemented following any NHSCFA engagement and there is evidence of demonstrable outcomes. Updates on the implementation of recommended actions are provided to NHSCFA upon request, in line with the NHSCFA’s engagement process.

Any corrective or preventative actions identified as a result of evaluation are implemented in line with agreed timeframes to ensure that counter fraud, bribery and corruption work continues to address organisational risks.

The counter fraud champion promotes awareness of fraud, bribery and corruption within the organisation.

The annual report on counter fraud, bribery and corruption work complies with the NHSCFA’s guidance in relation to content, directly referring to all applicable standards for fraud, bribery and corruption, and providing a clear update on progress against work plan objectives.

An appropriately signed statement of assurance is included in the annual report. A fully completed functional standard return is included with the annual report.

Where standards have not been met, the reasons for this are documented and corrective action is suggested for the following year.

The annual report also provides an update on progress made with any action points set out as part of the quality assurance process.

Organisation partially meets the requirement

There is evidence of proactive support for counter fraud, bribery and corruption work from senior management at the organisation. Support for the trained and nominated person carrying out counter fraud, bribery and corruption work on the part of the organisation is present and evident.

There is evidence that senior management recognises its responsibilities in relation to counter fraud, bribery and corruption work.

There is a counter fraud champion, however, little or no evidence of promoting awareness of fraud, bribery and corruption within the organisation.

Senior management ensures compliance with the requirements of the NHSCFA’s quality assurance programme. This includes ensuring that recommended actions are implemented in line with agreed timeframes following any NHSCFA engagement.

However, there is little or no evidence to indicate that this work has been evaluated for effectiveness by the organisation.

Organisation does not meet the requirement

There is no evidence of proactive support for counter fraud, bribery and corruption work from senior management.

There is no counter fraud champion.

Senior management demonstrates a lack of awareness of its responsibilities in relation to counter fraud, bribery and corruption work and organisational objectives in this area.

Senior management do not ensure that recommended actions are implemented in line with agreed timeframes following any NHSCFA engagement and there is no evidence of demonstrable outcomes. Updates on the recommended actions are not provided to the NHSCFA upon request.

There is no evidence that the organisation has completed an annual report demonstrating progress against counter fraud, bribery and corruption objectives.

Where an annual report has been completed, it does not cover all key areas of counter fraud, bribery and corruption activity as outlined in the NHSCFA’s strategy. The report does not provide a full update on actions taken to counter fraud, bribery and corruption as outlined in the work plan for that year. Where an NHSCFA engagement has been conducted, there is no update on the progress made against the recommended actions.

The annual report does not contain a fully completed functional standard return against the standards or a statement of assurance. There is no evidence that the annual report has been reviewed or signed off by the organisation.

Guidance, supporting documentation and evidence

Organisations should consider the following (the list is not exhaustive):

  • The NHSCFA strategy
  • Meeting minutes, decisions, action points and records of their execution, particularly for decisions taken at board level
  • Audit committee minutes evidencing monitoring and evaluation of counter fraud work conducted in compliance with the counter fraud functional standard
  • Documentation from the nominations process
  • A nominated Counter Fraud Champion.
  • Communications to staff directly attributed to the Counter Fraud Champion
  • Counter fraud, bribery and corruption work plan
  • Communications to staff directly attributed to the chief executive and/or board members, particularly communications to all staff
  • Documentation arising from any NHSCFA engagement process
  • Evidence of the implementation of any recommendations made by the NHSCFA as part any engagement
  • NHS Audit Committee Handbook (relevant sections)
  • Evidence that the Audit Committee Chair has an NHS.net account or an organisational account
  • Annual report on counter fraud, bribery and corruption work
  • Fully completed functional standard return
  • Relevant meeting minutes, action points and records of their execution
  • Action plan made as part of any NHSCFA engagement