No practice can afford to lose money especially in the current climate. Fraud is preventable as long as you have the right measures in place and you know how to spot it
The public sector loses more than £20 billion annually as a result of fraud.1 And the size and complexity of the NHS, as well as its £110 billion annual budget, make it particularly attractive and vulnerable to fraudulent activity. This may involve deliberate deception that is committed for financial gain or for other kinds of personal advantage, and may in some cases result in substantial loss or damage to the individuals or organisations concerned. It is therefore vital that opportunities for crimes such as fraud, bribery and corruption are minimised, to ensure the greatest possible protection for both people and resources (see Box 1).
Safeguarding the NHS from crime is a challenge for all providers and commissioners of NHS services. This includes general practices and is reflected in the current NHS standard contract that requires counter fraud and security management arrangements are in place.2
Compliance with this aspect of the contract is also reinforced through the Care Quality Commission (CQC) standards for regulating general practices that require robust procedures to identify and manage the range of risks that could affect the safety and quality of patient care.3 Adherence to these will also need to cover those areas at risk of fraud and associated crimes. Consider, for example, the following selection of Key Lines Of Enquiry (KLOEs):
- “Do staff have the skills, knowledge and experience to deliver effective care and treatment?”
- Employment processes should always be rigorously followed, whether employing permanent staff or locums/temporary staff through agencies. This should include checking and verifying qualifications, registration and references as well as the relevant criminal record disclosure and barring checks.
- “Do the governance arrangements ensure that responsibilities are clear and that quality, performance and risks are identified, understood and managed?”
- This requires the active management of all risks with appropriate controls including regular review of governance arrangements and fraud prevention processes.
- “How does the leadership and culture reflect the vision and values, encourage openness and transparency and promote good quality care?”
Practice culture should promote an atmosphere in which staff are encouraged to report any wrong doing, including fraud, bribery or other corruption.
Regular reviews of key aspects of practice activity are essential in order to identify and manage the risk of fraud and associated crimes that may be perpetrated by individuals within, or external to, the practice. These include the following.
Bogus information may be given on job applications:
- Failure to carry out the necessary checks has resulted in cases where individuals who were neither properly qualified or registered have been employed as practice nurses.
- Falsifying qualifications may not only give an applicant a pecuniary advantage, it could also expose patients to harm.
The appropriate criminal record and barring checks should be made when the roles and responsibilities of the post require this. Some key points to remember:
- Checks are not only for health professionals but non-clinical staff too.
- Wherever disclosure of criminal conviction is required for a post, ensure that staff are also aware they have an ongoing duty to disclose any new convictions.
- Dishonest employees may make fraudulent expenses claims.
- Individuals responsible for the upkeep of financial records and payroll administration may abuse their positions to make unauthorised payments to themselves, either through salary increases or the creation of ‘ghost’ employees (See Box 2, Case study 1).
The supply of goods and services
- Risks include suppliers or staff acting alone or in collusion with others to falsify invoices. These may be for inflated sums or non-existent goods or services (See Box 2, Case studies 1 and 2).
- This is an area where procurement processes may be undermined as a result of bribery or corruption.
Fraudsters may register on a temporary or permanent basis with a number of practices using their own or false details in order to obtain prescription drugs, either for personal use or resale (See Box 2, Case study 3).
This is an area at particularly high risk of fraud, by individuals either from outside or within the practice. Issues include:
- Forged or altered prescriptions.
- Duplicate prescriptions.
- Income from prescriptions being retained by staff, while claiming exemption for a patient.
- Patients claiming exemption from prescription charges when they are not entitled to do so.
Fraudulent crime cannot be eliminated but it can be made as difficult as possible to perpetrate without being detected. It is more likely to succeed or go undetected for a long period where:
- Fraud prevention is not prioritised.
- Risks are not regularly reviewed and actively managed.
- Monitoring of security, including IT and data management security is infrequent.
- Adherence to standard operating procedures is poorly enforced.
- Controls are weak or untested.
- Independent audits are not routinely carried out.
An important defence against fraud, bribery and corruption is through building a strong practice culture where such behaviour is seen as unacceptable. Where staff feel supported, respected and valued the motivation to commit even minor fraud is greatly reduced.
Training is vital to raise awareness of the practice’s anti-crime policies and procedures, as well as emphasising the importance of personal and corporate responsibilities. Case studies and everyday examples can be particularly helpful. This will ensure that staff appreciate the consequences of inflating expenses claims whether for miles travelled or hours worked. Seemingly small amounts can mount up if there is no regular scrutiny or other deterrent.
Training also needs to cover issues relating to conflicts of interest as well as to the Bribery Act.4 Particular areas of risk include the procurement process where staff may be dealing directly with contractors or in relation to the provision of goods and services.
Bribery may involve gifts, hospitality, or any other financial or non-financial inducement that may potentially influence decision-making in favour of the individual(s) or organisation providing the inducement.
All staff should know what to do if they suspect or witness fraudulent activity. They should be familiar with the NHS counter fraud arrangements provided at national level by NHS Protect and by the local counter fraud specialists (LCFS) (see Resources).
Countering fraud, bribery and corruption is a serious challenge for all healthcare organisations. By reviewing and strengthening your practice’s anti-crime arrangements and culture, you can help protect patients, staff and stretched NHS resources from the damaging consequences of fraudulent activity.
Anne Ward Platt, BA(Hons) PGCE, director, WP Medical & Professional Services.
1 National Fraud Authority. Annual Fraud indicator. 2012. gov.uk/government/uploads/system/uploads/attachment_data/file/118530/annual-fraud-indicator-2012.pdf (accessed 5 September).
2 NHS England. NHS England Standard General Medical Services Contract 2015/16. england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/06/gms-2015-16.pdf (accessed 5 October).
3 Care Quality Commission. How CQC regulates NHS GP practices and GP out-of-hours services. Provider handbook. 2015. http://www.cqc.org.uk/content/gp-practices-and-out-hours-service-providers (accessed 25 September).
4 HM Government. Bribery Act (2010). London: The Stationery Office, 2010.
1 NHS Protect leads on the provision of counter-fraud services for the NHS in England and Wales, and security management services in England (nhsbsa.nhs.uk/fraud).
NHS fraud and corruption reporting line: 0800 028 40 60
Online reporting: http://www.reportnhsfraud.nhs.uk/
All information is treated confidentially and may be given anonymously.
2 Fighting Fraud Together. The strategic plan to reduce fraud. https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil… (accessed 4 September).
3 NHS Employers. Criminal record and barring checks. www.nhsemployers.org/publications (accessed 4 September).