Working Patterns

The “traditional” working pattern of Monday to Friday 9 – 5 has never really applied to most medical/clinical professionals but, until Covid-19, it did apply to many desk-based NHS professions. Since the pandemic,
working patterns have changed significantly for nearly everybody, for several reasons:

1. Flexibility - This means that workers have a degree of flexibility over where, when and how they work. Flexible working refers to the number of hours worked and when these are worked, including flexitime and compressed hours. This also enables them to undertake other roles and jobs around their core NHS work, as secondary employment.
2. Remote Working - Remote working refers to a type of flexible or ‘agile’ working based on location, where workers work at home or a location other than the traditional workspace where the employer is based, and not necessarily in the same region or country.
3. Hybrid Working - Hybrid working refers to a combination of office and home / remote working arrangements.
4. Bank / Agency Working - With so many vacancies in the NHS, staff work bank / agency shifts on their off-duty days. Many in the NHS have also made the decision to not hold a substantive position at all, and instead work solely via Banks or via Agencies, taking total control of when and how often they work. This can also enable them to take on other jobs and roles away from the NHS. 

Per the UK Government Research paper from 2022 “The impact of remote and hybrid working on workers and organisations” before the pandemic, remote and hybrid working had been increasing gradually.

In 2019, around 1 in 10 (12%) of the of the UK workforce had worked at least one day from home in the previous week and around 1 in 20 (5%) reported working mainly from home.

A Forbes survey in 2024 “Top Remote Working Statistics and Trends in 2024 – Forbes Advisor UK” showed 39% of workers worked from home, and 24% worked to hybrid arrangements, accounting for more than half of the workforce.

Many people also have a “side-hustle.” This means an income-generating project conducted by an individual, or group of individuals, in addition to a main income. Examples of this are renting out a room, or your vehicle, or creating something to sell on Etsy / Ebay or similar.

Many of these creative endeavours were initially established when a lot of the workforce was on ‘lockdown’ during 2020.

The increase in flexible working brings its own fraud risks, in that the management of an employee who works at home / flexibly must be of a “lighter touch”. A manager cannot always physically see their employees conducting their work, as would be the case if they were both in a shared office, and consequently, there is a greater level of trust or understanding required that the employee is conducting the work they should, in the times they should be conducting it.

Operation Falkirk (agency worker fraud)

The NHS Counter Fraud Authority produced a Learning Report in August 2024 around an NHS fraud case that they entitled ‘Operation Falkirk’.

This case involved a senior nurse employed for several months through an agency to work remotely on a full-time basis for an NHS organisation (Entity A), and towards the end of the period, this employee, presumably erroneously, asked their Line Manager to approve a timesheet that was for a different NHS employer (Entity
B), and the hours contained on this timesheet overlapped the hours they should have been working for them.

The nurse had joined a department where substantive staff worked flexibly, but with set core hours, and these had not been explained to the nurse, as they were an agency worker.

The individual had not declared to Entity A that they also worked for Entity B, and had in fact completed a Declaration of Interest form with no conflicts of interest recorded; but which was completed more than two months into their period of employment. Listen to the Conflicts of Interest episode of the MIAA Talking Fraud podcast.

Once this issue had been identified, the Line Manager admitted that their output had been poor and they were responding to emails outside of the agreed work hours. As well as this, the nurse had raised concerns with their Line Manager that they were struggling with their workload.

None of this had been dealt with prior to the Entity B timesheet being provided. It is incumbent on any Line Manager to deal with poor performance as and when it arises, rather than wait till the next 1-2-1 / appraisal. Similarly, the red flag of responding to emails outside of their work hours had been ignored.

The agency was a framework organisation but, on investigation, the agency had deemed the nurse ready to work several years previously and conducted no further checks on their suitability since, despite the nurse having worked at several other NHS organisations in the interim period. Entity A did not confirm with the agency whether any recent checks had been carried out on the nurse’s suitability to work. 

The investigation identified that the Line Manager was simply signing the nurse’s timesheets and not conducting any verification that the hours had been worked.

Working Whilst off Sick

This is the most common staff fraud in the NHS, but it can be more complicated to identify an occurrence given the increase in flexible working arrangements, and also to obtain evidence of any fraud once it has been reported.

Agency work is so prevalent within the NHS that fraud referrals made about NHS employees who are off sick from their NHS employer remain the most prevalent staff fraud, particularly when working via an agency.
Referrals have included staff working via an agency at their own Trust (normally at a different location or ward, but not always).

Working elsewhere whilst off sick is a potential fraud offence (Section 2, Fraud Act 2006 – Fraud by False Representation) and the maximum sentence can be up to 10 years in prison.

Technically, if you are absent from your NHS employer through sickness, or other paid absence such as maternity or compassionate leave, and you work elsewhere during these periods, either paid or unpaid work, or take part in any training, you may have committed a fraud offence.

If you are not able to work your main role, and your Fit Note from your GP says you are unable to work, you generally should not work anywhere else, particularly doing the same role. However, this is not as black and white as it appears. There are reasons why you could be permitted to work somewhere else:

• Your Fit Note specifically states that you are permitted to continue to work in a specified “other” role.
• You are absent because of stress / depression / anxiety, particularly if work related, and your secondary role could be deemed to be good for your mental health (for example, baking cakes and selling them to your contacts via social media).

There are also variations in how rules are applied between NHS bodies. One Trust may say to their medics that when their Job Plan states “Admin / SPA” they physically have to be on-site conducting this specific activity, whereas another may accept that as long as a medic remains up-to-date with their administrative tasks and medical knowledge, they may be more flexible as to when this activity is conducted and they can work at the nearest private hospital during their Job Plan time.

There is also case law in relation to this type of fraud. In Perry vs Imperial College Healthcare NHS Trust, it was deemed that an employee was unfairly dismissed from their role as a community midwife for continuing to work at a desk-based role while off sick with a knee injury.

If there are a variety of ways of working your substantive role, it can be less clear whether someone is committing this fraud offence. If one NHS worker sees their co-worker in a uniform working at a care home and they know they are on sick leave, do they know whether this secondary role is permitted per their fit note? Do they know the reason for their sickness in the first place? Are they conducting a role at the care home that differs from their primary role? Has this other role already been declared?

When we conduct fraud awareness presentations, we are sometimes asked if you are allowed to work agency shifts while on maternity (or paternity) leave. This partly depends if there are prior agreements in place, such that someone on maternity leave can conduct a small number of bank / agency shifts in order to get ready for their return to full-time (or part-time) role.

Having said that, there have been successful prosecutions within the NHS for staff working a second Job while on sick leave. A neurology nurse at a London NHS Foundation Trust was convicted of fraud after working nursing shifts while absent through sickness from their substantive post. The nurse was sentenced to 16 months’ imprisonment and had to pay back the fraud overpayment of £32,000 to the Trust. 

Advice to HR /Workforce / Line Managers regarding Staff (Direct and Agency)

Staff performance and attendance should be monitored alongside an individual’s outputs, and issues should be addressed in a timely manner.

Line managers should regularly “check-in” with remote workers. This is to identify any issues from the remote worker’s perspective, but also as part of their management. Consider conducting appraisals only in person. Make a note as to how accessible and contactable they are, or whether there’s always a delay in them replying.

In addition, watch out for ‘red flags’ that there is an issue with someone working hybrid / remotely. Examples of which are:

• An individual never answers their phone / Teams calls, they always phone you back.
• They can never attend the office on certain days.
• Consistent pattern of sending emails outside working hours.
• Delays in responding to emails perceived as important.
• Emails involving work tasks that forwarded on from a third-party source.

Consider adopting a Flexible / Hybrid Working Policy, if one doesn’t already exist – or update it, if it was drafted during the pandemic.

Ensure that contracts of employment and HR policies reflect the increase in hybrid and remote working, specifying core hours and required ‘office’ times. Also, review related policies and procedures to consider all potential remote working risks, i.e. not undertaking sensitive work in public places such as coffee shops or where Wi-Fi facilities are insecure.

Managers should check timesheets and consolidate these against other records to confirm the hours have been worked, prior to authorising.

The authorisation of timesheets should not be delegated and in the first instance should always be completed by direct line managers.

Know what other employment has been declared by staff you manage, and ensure their declarations are completed on an annual basis. Consider establishing a Secondary Employment Policy, if one doesn’t already exist. Update it, if it’s out of date or non-reflective of current permitted practices.

When you are provided with a Fit Note, always read what the Fit Note says, including any exemptions. Look at what the Fit Note prohibits or allows.

As part of the Return to Work process, ensure that a question is asked about whether they have undertaken any work, paid or unpaid, and that their response is recorded. Follow-up, if they indicate that they have. Conduct verifications on the pre-employment checks undertaken by any and all agencies at regular intervals, whether they are Framework or non-Framework organisations. You could ask your Internal Audit or the Anti-Fraud Specialist to conduct a review of these checks for you, or conduct spot-checks yourself. 

Obtain a declaration of any interests from all new employees. For agencies, consider ensuring that any potential conflicts are addressed by the agency as part of their contractual requirements before providing agency staff to the health body. Watch our short Conflict of Interest Video here.

Reporting Concerns / Obtaining Advice

If you see or hear of an NHS employee working while they are absent on paid sick or other paid leave from their NHS employer, please consider reporting this to your Anti-Fraud Specialist. It may or may not be fraud, but the Anti-Fraud Specialist can make appropriate enquiries.

Alternatively, you can also report your suspicions anonymously by contacting the NHS Counter Fraud Authority Freephone 0800 028 40 60 or online at www.cfa.nhs.uk/reportfraud.

By reporting suspicions, you can help the NHS put money back into patient care and bring offenders to justice.

Contact our fraud team