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Whoever lives by the fraud … shall perish by the fraud

6 June 2008

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Barry Hill

Freelance medical journalist

Chief Biomedical Scientist
Wigan Royal Infirmary

Barry has worked within pathology for more than 30 years, specialising in blood transfusion and haematology. He is also a prolific writer of articles for a wide range of pathology, nursing and GP-based publications. Outside of work, Barry enjoys walking the beaches of Anglesey with his family, as well as playing guitar and harmonica to emulate his hero, Neil Young

In 2005, a 57-year-old former Huntingdon GP was jailed for two years for committing a large-scale false accounting fraud against the NHS. The fraud would have cost the NHS £150,000, had he not been caught and prosecuted by the NHS Counter Fraud Service (NHS CFS).

The GP in question had taken advantage of his practice’s licence to dispense medication as well as prescribe it. He would make out prescriptions in the name of patients on his list, claim payment from the NHS, and then cancel the entry on the patients’ records so payment was made but no medication was ever dispensed.

The offences took place over a period of 15 months, and came to light when routine checks by Huntingdonshire Primary Care Trust (PCT) revealed discrepancies in his prescribing. The PCT referred the case to the NHS CFS, which conducted a thorough investigation, resulting in the prosecution and the sentence.

This is just one example of the work of the NHS CFS, part of the NHS Counter Fraud and Security Management Service, which has responsibility for preventing, detecting and investigating fraud against the NHS, and ensuring the security of its staff and property.

The NHS CFS was established in 1998, and quickly discovered that all parts of the NHS have been exposed to, or are vulnerable to, fraud. So successful has it been in preventing fraud since its inception that it has to date recovered some £51m, which has been reinvested into healthcare, and prevented and stopped even more money being lost to the health service.

Types of fraud
Fraud in the NHS comes in many different guises and can be committed by practically anyone. According to Dermid McCausland, Managing Director of the NHS CFS, there is no single profile of an NHS fraudster; previous examples of NHS fraud have been committed by patients, relatives of patients, GPs, nurses, consultants, contractors and even NHS trust
chief executives.

“There is an enormous variation in the types of fraud that are committed, as there are people who commit them,” says Mr McCausland. “We take every case, no matter how big or small, very seriously. Allegations of fraud are always investigated thoroughly and professionally. Where fraud is proved, we always press for the toughest possible sanctions.”

Among the more recurrent kinds of fraud are theft, staff claiming money for shifts they have not worked (“timesheet fraud”), patients falsely claiming exemption for optical, dental or pharmaceutical charges (“prescription fraud”) or staff working in unauthorised jobs while on sick leave.

“Our fraud work encompasses preventing the illegal obtaining of money, services or resources from the NHS by deception and detecting, and taking action where prevention is not possible,” says Mr McCausland, who has more than 18 years’ experience of countering fraud in a public sector environment.

“I see my role as one of ensuring that we continue to deliver real financial benefits and savings to the NHS by ensuring monies lost to fraud are recovered and returned. Mechanisms have been introduced to assist this, which utilise the goodwill of the honest majority who work in or use the NHS to deter the dishonest minority from committing fraud.”

Cost to the NHS
Although fraud detection is steadily improving, a considerable amount of money is still being lost to the detriment of the NHS, as Mr McCausland outlines.

“Fraud reduces the NHS of valuable resources intended for patient care and could even cost lives,” he says.

Not only has the NHS CFS been an extremely cost-effective measure to date, but it also prevents future losses through deterring and preventing fraud from occurring.

Mr McCausland believes that instilling an antifraud culture into the workplace is integral to this: “This creates an awareness of what constitutes fraud, how the NHS suffers and what action can be taken, therefore ensuring that honest staff and patients themselves remain vigilant against fraudsters,” he says.

In terms of actual prosecutions, the NHS CFS has had impressive results. Over the last five years, they have investigated more than 1,900 cases of suspected fraud, resulting in 422 criminal prosecutions and 341 civil or disciplinary sanctions.

Fraud in the GP surgery
In his time at the NHS CFS, Mr McCausland has seen practically every type of fraud. However, he is still surprised by what
is uncovered.

“Recently we prosecuted a GP practice manager for committing a £54,000 fraud,” he says. “She abused the payroll system to award herself extra hours and increase her pay. In order to continue working past her retirement age, she also doctored her date of birth on the practice computer system to make herself four years younger. This meant she received both a salary from the practice and payments from a private pension the practice set up. The fraud was discovered following an audit by the local PCT, which resulted in an 18-month suspended jail sentence.

“In another case involving prescription theft, a patient deceived GPs out of more than 2,000 tablets by using more than 20 different identities to obtain prescriptions for painkillers. He used the false identities to register with various GP practices in the Hampshire area in order to be prescribed the painkiller dihydrocodeine.

“He also went to emergency out-of-hours centres claiming that he was registered with local GPs, and obtained more than 2,000 tablets before he was eventually caught.

“The fraud was discovered when GP practices reported that prescriptions had been issued to an individual who had falsely claimed to be registered with them. The local counter fraud team investigated, and found that many of the claims used the same telephone number or address, even though the names were different.

“We also had a prescription theft case involving a GP receptionist who, several times a week over the course of two years, forged codeine phosphate on repeat prescriptions for genuine patients and then took them to various pharmacies in the area for dispensing.

“She told the pharmacy that she was acting as a representative for the patient involved and obtained between 50 and 112 tablets on each occasion. She was dismissed from the medical centre and later sentenced to a 200-hour community punishment order. We have even seen cases where GPs have not paid pension contributions for their practice staff.”

Eyes and ears
Ultimately, the aim of Mr McCausland and his colleagues is to reduce fraud to an absolute minimum; but to do this they need help.

“Fraudsters are determined people and are constantly looking for new methods of cheating and defrauding the NHS,” says Mr McCausland. “I believe the NHS CFS must learn from every type of fraud and put effective measures in place to stop them happening again.

“Our aim is to raise awareness levels to fraud and to encourage healthcare staff and the public to report it where they see it, and assure them it will be acted upon. Then we will be an organisation that is fully equipped to deal with each and every new fraud we encounter.”

He believes that as long as the fraudsters are out there, all health professionals can play an important part in helping to combat these crimes.

He says: “GPs, practice managers and their staff are our eyes and ears on the frontline of the NHS. Should they have any suspicions of fraudulent practice or the mismanagement of NHS funds, it is essential they report it to their local counter fraud specialist or via the NHS Fraud and Corruption Reporting Line [see below] at the earliest possible opportunity.

“Fraud against the NHS is not a victimless crime. It is patients who are losing out.”

NHS Counter Fraud and Security Management Service

NHS Fraud and Corruption Reporting Line
0800 028 40 60
(Freephone Monday–Friday, 8am–6pm)