The Government will work with GPs to tackle fraud relating to inappropriate claims and reimbursements and ‘contractual fraud’ to help meet a savings target of £500 million for the NHS between now and 2026.
The Department of Health and Social Care (DHSC) has launched a counter fraud strategy that identifies primary care (including dentistry and pharmacy) as one of three key risk areas it will focus on in the next three years. The £500m savings will come from prevention and detection of fraud as well as the recovery of funds, it said.
It is estimated that the NHS in England is vulnerable to £1.198 billion of fraud, bribery and corruption each year.
Data from the latest NHS Counter Fraud Authority (NHSCFA) Strategic Intelligence Assessment report, which has been used to develop the new counter-fraud strategy, showed that between 2021 and 2022 the financial amount vulnerable to GP fraud was estimated at £101 million – out of an expenditure of £10.1 billion (see also box below).
During 2021/22, there were 160 allegations of GP fraud made to the NHSCFA.
In the same period, the estimated financial vulnerability to fraud for community pharmacists was £122 million and for dental contractors was £61 million.
A spokesperson for the DHSC told Management in Practice that a key part of the 2023-2026 counter-fraud strategy is ‘ensuring that, wherever possible, fraud is prevented from occurring in the first place by working with stakeholders, such as GPs, to identify any weaknesses in the system that can be closed’.
Its policy paper says it will take a data-driven approach and make counter-fraud a ‘part of day-to-day activity’. One objective will be to ensure staff ‘understand fraud and how it could impact their work, and their roles and responsibilities to prevent it’ as well as make sure they feel confident to report suspected fraud early.
It also says it will ‘continue to use a range of options to deal with those who commit fraud, allowing proportionate and cost-effective action to be taken’.
Lord Markham, parliamentary under secretary of state at the DHSC, said: ‘Every pound lost to fraudsters is a pound lost from patient care.’
He added: ‘The methods and means of attack from fraudsters are constantly changing and I am determined that we not only keep pace but anticipate their actions. No level of fraud is acceptable, and DHSC and its partners will do even more in response to this threat, with an ambitious new three-year strategy target of £500 million.’
The other two areas the government will focus on as part of its drive against fraud are procurement and commissioning and prevention policies.
What does fraud in general practice look like?
The NHSCFA Strategic Intelligence Assessment 2022 report said: ‘Fraud in this area is generally considered to be the manipulation of NHS income streams by practitioners or staff members. It could also be considered activities that violate NHS contractual terms for practitioners and services provided.’
It highlights the threat of organised crime groups (OCGs) potentially colluding with GPs to obtain prescription medication for selling.
The report says: ‘Intelligence suggests non-existent or deceased patient details have been used by GPs when prescribing medication for onward trade. OCGs may fraudulently obtain prescriptions, or even collude directly with GPs themselves.’
It also said ‘it’s likely a small minority of GPs could manipulate contracts to increase profit’ by using false records or declarations to secure funding or ‘deliberately fail to remove former patients from their lists, resulting in increased Global Sum payments’.
Finally, it added there is a ‘realistic possibility that practice employees may knowingly or unknowingly be complicit in supporting contract manipulations. The staff member may not directly benefit, but could potentially register ghost patients, or intentionally fail to remove patients from surgery lists.’
