NHS Fraud Awareness Presentation Staff Induction Event COUNTERING FRAUD IN THE NHS

NHS Fraud AwarenessPresentation

Staff Induction Event

COUNTERING FRAUD IN THE NHS

NHS Counter Fraud Service – set up in 1998 to:

Tackle all losses to fraud and corruption in every area of NHS spending.

Address problem of the minority who try to defraud the NHS of it’s valuable resources.

Reduce fraud to an absolute minimum and hold it at that level to release resources for better patient care.


What is Fraud?Stealing (dishonesty) with an element of deception.

Fraud Act 2006 simplified Fraud into 3 main areas:•Acts of Omission

•False Representation•Abuse of position

What is Corruption?

The offering, giving, soliciting, or acceptance of inducements which may influence a persons actions.


STRUCTURE:Central Unit: Operations

Quality & Training

Communications and Business Development

Policy

Risk / Security Management Unit

Specialist Teams: Dental Fraud Team

Pharmaceutical Fraud Team

National Proactive Team

Regional Teams: Counter Fraud Specialists

Local Teams: Local Counter Fraud Specialists


Your Local Counter Fraud Specialist

Every health body in England & Wales has a nominated LCFS to tackle fraud at local level.

Professional accreditation process.

First point of contact to report concerns re fraud.

East Midlands NHS Local Counter Fraud Services

- Arrangements-

-Team approach-


PERFORMANCE STATISTICS 2007/08

351 cases detected and investigated£4.1m fraud and unlawful action identified£7.5m potential savings from completed

investigations£6m recovered (57.5m since 1998)

69 civil and disciplinary sanctions applied96% Prosecution success rate


Types of Fraud We Investigate

Illustration of what kind of fraud occurs in the NHS and some actual case studies…

Investigations have covered the whole spectrum of people working in, and using, the NHS.


ABUSE OF POSITION

Background• Modern Matron forged signatures on timesheets and

swindled over £8,000 from NHS. • Claimed most of the total overtime bill for nurses and

midwives. • Faked manager’s signature on claim forms. • Claimed overtime whilst off-sick and once when she was

on holiday abroad.

Outcome• Sentenced at Leicester Crown Court to 240 hours

community punishment • Ordered to pay £1000 costs. • The Trust is currently recovering the defrauded sum.


WORKING ELSEWHERE WHILST ON SICK LEAVE FROM NHS EMPLOYMENT

Background• Dietetic Assistant seen working at a private nursing home

by a patient. • The patient mentioned this to staff who were aware the

employee was on long-term sick leave and reported it to management.

Outcome• Confirmed they had been working whilst claiming sick pay. • Charged with four counts of false accounting.• Sentenced to 120 hour Community Punishment Order and

declared bankrupt before the £4,000 defrauded funds could be recovered.


FICTITIOUS MILEAGE CLAIMS

Background• Doctor found to have made eight excess travel claims for 175

journeys totalling 21,000 miles. • Falsely claimed excess travel claims between Hull and Leeds

hospital, when they had been living in Leeds the whole time.

Outcome• Resulted in a £4,800 loss to the NHS. • Doctor pleaded guilty to eight offences of false accounting. • Sentenced to a 12 month Community Punishment Order. • Money repaid to the NHS.


JOB APPLICATIONS – NON-DECLARATION OF CONVICTIONS

Background• Temporary medical secretary caught claiming longer hours

than she had actually worked. • Forged the authorised signature on the timesheets. • Later applied for a permanent position failed to declare

criminal record. Found to have three previous convictions, including a two-year prison sentence for theft from an employer.

• Outcome• Pleaded guilty to obtaining a pecuniary advantage and three

charges of false accounting. • Sentenced to four months imprisonment for each offence• Ordered to carry-out 150 hours community and to pay £150

compensation and £750 court costs.


FRAUDULENT CLAIMS BY DENTISTS

Background• Dentist claimed payment for numerous treatments that had

never been provided. • Created over 800 non-existent patients to claim even more

money. • 3,800 false claims for payment to the NHS.

Outcome• Pleaded guilty to fifteen charges of obtaining money

transfers by deception. • Sentenced him to four years imprisonment. • Total loss to the NHS was over £600,000. The case was

referred to the GDC for disciplinary action.


OPTICIANS - FALSE CLAIMSBackground• Optician accused of forcing five employees to take part in

the fraud by making numerous false and inflated claims for payment.

• They had issued spectacles to children when none had been dispensed.

• Claimed payment for full replacement of spectacles, when in fact the original spectacles had been repaired.

Outcome• Optician found guilty of conspiracy to defraud and

sentenced to two years imprisonment. The fraud was worth about £200,000.

• Three employees pleaded guilty and were sentenced to 12 months imprisonment, suspended for 2 years.


Patients – claiming exemptions / hospital travel to which not entitled.

Background

• Patient pretended to be undergoing treatment for cancer at DRI. She also turned up at the Hospital's reception wearing a head scarf, claiming that she was suffering hair loss as a result of chemotherapy. She told hospital staff that she had had one lung removed and had cancer in the other.

• Staff from the Trust checked records and discovered that she had never received treatment at the hospital and no serious illness had been identified.

• Receipts from a local transport company were altered to make it look like she had attended the hospital.

Outcome

• The patient pleaded guilty to all charges and 52 TIC’s at Derby Magistrate's Court. She was sentenced to a £100 fine, £75 costs, and a compensation order amounting to £961.90 and £30 per week re-payments.


FraudstersFraudsters

OpportunityOpportunity – weak management or poor – weak management or poor system controlssystem controls

MotivationMotivation – strong reason to resort to – strong reason to resort to fraudfraud

RationalisationRationalisation – the ability to justify their – the ability to justify their actionsactions


Fraud IndicatorsFraud Indicators

Stress without high workloadStress without high workloadFirst in last out, reluctance to take leave, refusal of First in last out, reluctance to take leave, refusal of

promotionpromotionEgotistical, risk taker, rule breakerEgotistical, risk taker, rule breaker

Disgruntled, a complainerDisgruntled, a complainerUnexplained wealthUnexplained wealth

Sudden change of lifestyleSudden change of lifestyleNew staff resign quicklyNew staff resign quickly

Suppliers/contractors deal only with one personSuppliers/contractors deal only with one personGreedy or has genuine financial needGreedy or has genuine financial need


Group ExerciseGroup Exercise

Work in small groups.Work in small groups.

Identify one area where you feel your directorate/department Identify one area where you feel your directorate/department may be vulnerable to fraud.may be vulnerable to fraud.

What might indicate fraud was occurring in this area?What might indicate fraud was occurring in this area?

How would you stop it?How would you stop it?

You have 5 minutes to do this.You have 5 minutes to do this.


LCFS Work - Not just investigations….

Developing an ANTI-FRAUD CULTURE.

Maximum DETERRENCE of fraud.

Successful PREVENTION of fraud that cannot be deterred.

Prompt DETECTION of fraud that cannot be prevented.

Effective SANCTIONS against people committing fraud.

Effective methods for seeking REDRESS of defrauded money.


The NHS Counter Fraud Service

Details regarding the work of the NHS Counter Fraud and Security Management Service, and further examples of actual frauds that have been perpetrated against the NHS, can be found on their website:

www.nhsbsa.nhs.uk/counterfraud.aspx


If you are concerned about a fraud taking place within the NHS, you should either:

1. INFORM THE ORGANISATION’S NOMINATED LCFS:Leicester City PCT – Richard HolmesT: (0116) 295 3166. E: [email protected].

Joanna Clarke T: (0116) 295 3159. E: [email protected]

NHS Leicester County & Rutland and Leicester Partnership Trust – Richard Holmes T: (0116) 295 3162. E: [email protected] Joanna Clarke T: (0116) 295 3159. E: [email protected]

2. CALL THE CONFIDENTIAL NHS FRAUD & CORRUPTION REPORTING LINE : 0800 028 40 60 (Freephone – Mon to Fri – 8am-6pm)

3. COMPLETE A CFS1 REFERRAL FORM.

All calls are: Treated in the strictest confidence. Dealt with by trained staff. Professionally investigated.


Documents

NHS Fraud Awareness Presentation Staff Induction Event COUNTERING FRAUD IN THE NHS