The NHS Counter Fraud Strategy

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1 The NHS Counter Fraud Service exists to minimise losses through Fraud & Corruption. Every year millions of pounds of public money are at risk to fraud and corruption in the NHS. A small minority of people feel that it is acceptable, by their criminal behaviour, to deprive the NHS of resources which would otherwise be used to provide patient services. The NHS Counter Fraud Service was established in The NHS Counter Fraud Strategy The Chief Executive and Director of Finance are jointly responsible for ensuring compliance with Secretary of State Directions (or in the case of Foundation Trusts, the Independent Regulator s Licence). Every Health Body in England & Wales must nominate an Accredited Local Counter Fraud Specialist (LCFS) to undertake counter fraud work in 7 generic areas of activity. AIM: To reduce fraud within the NHS to an absolute minimum and hold it permanently at that level to free up resources for better patient care The Counter Fraud Structure Secretary of State NHS Business Service Authority NHS Protect Area Counter Fraud Specialist Director of Finance/ Chief Executive Local Counter Fraud Specialist Trust employees, patients, visitors and contractors 1

2 Is the Counter Fraud Service effective? Between 1999 and 2010: Nationally In 2009/10 alone: More than 65 million was recovered; Approximately 824 million was saved; and There were 616 successful prosecutions. During the 2 year period ending 31 st March 2010, EMIAS Local Counter Fraud Specialists: Received 268 referrals; Brought 236 investigations to conclusion; Identified 107 system weaknesses; Obtained 21 criminal convictions, 54 disciplinary sanctions and 12 awards by civil action; Identified fraud losses totalling 1.24m ( 1m recoverable); and Brought the Counter Fraud message to almost 24,000 NHS staff. 4,182,758 in potential savings were identified; 2626 investigations were concluded; there were 150 successful prosecutions; and 583 civil and disciplinary sanctions were applied. A former Healthcare Support Worker for NHS Calderdale was sentenced to 4- months imprisonment suspended for 12 months and a 12-month Supervision Order for failing to report 21, worth of salary overpayments. The woman had left the Trust to have a baby and was aware that she was not entitled to statutory maternity pay, having only been employed by the Trust for a short time. However, a year later an error in the Trust s payment system reactivated her salary payments, even though she had decided not to return. The payments continued for the next 22 months, the woman even sending details of her new address and bank account to the payroll department. The overpayments were discovered during a new manager s audit of absence reports. An internal investigation was conducted and the matter was subsequently referred to the Local Counter Fraud Specialist for action. 2

3 What is Fraud? In the simplest of terms, Fraud is theft with an element of deception involved. The most common offences under the Fraud Act 2006 are: Fraud by false representation: e.g. submission of false timesheets for shifts not worked Fraud by failing to disclose: e.g. failing to declare criminal convictions when applying for NHS employment Fraud by abuse of position: e.g. a person in a position of trust using their position to commit fraud (Some fraud offences, committed before 15 th January 2007, continue to be prosecuted under the Theft Acts). What is Corruption? Corruption is defined as the offering, giving, soliciting or acceptance of inducements which may influence a person s actions. For example, a supplier making a payment to a staff member to secure a contract or to supply goods or services in excess of actual requirements. The Trust may, as a result, fail to achieve value for money or pay for goods not required. A Nursing Auxiliary and Catering Assistant working for NHS Leicestershire County & Rutland was sentenced to 150-hours Community Punishment and ordered to repay 3, in overpaid sick-pay. The woman had been receiving pay from the Trust for a period of longterm sickness, but during this time had undertaken regular work at a private care home. This was discovered when a relative of a Trust patient saw the woman when visiting the private care home. The matter was reported to the LCFS and an investigation was conducted, culminating in a case being brought before Melton Magistrate s Court. The woman pleaded guilty to all charges and was also ordered to pay 400 costs. 3

4 Examples of potential Fraud & Corruption in the NHS Submission of false timesheets for shifts not worked; Employees claiming NHS sick pay when actually working for another employer; False declarations of employment history/ qualifications in order to gain employment; Submission of false/ excessive expense claims; Submission of false quotes, invoices or receipts in order to obtain financial reimbursement (staff & suppliers/ contractors); Contractors claiming for goods/ services not supplied; Diversion of charitable donations for personal benefit; Failing to report receipt of salary (or other) overpayment; Employees conducting personal/ private business in work time; Unauthorised use of NHS equipment/ facilities for personal gain; Acceptance of gifts and inducements for third party advantage; Patients falsely claiming entitlement to NHS treatment/ services; Patients falsely claiming exemption from NHS charges. A cardiothoracic doctor was sentenced to 12-months Community Punishment for a 4,800 fraud against the NHS. The doctor from a Leeds-based Trust, made eight excess travel claims for 175 journeys totalling 21,000 miles. He had falsely claimed to be living in Hull, giving him an entitlement to mileage allowance for travel to and from the hospital, when he had actually been living at his home in Leeds. The doctor pleaded guilty to the charges at Leeds Magistrates Court and was sentenced to 12-months Community Punishment, as well as being ordered to repay the defrauded money to the Trust. The case was also referred by the LCFS to the General Medical Council (GMC) and a bar was placed on his record to prevent further career progression. 4

5 What do I do if I think a Fraud is occurring? Don t investigate the matter yourself or report it to your manager- this may compromise any potential prosecution. Don t undertake any surveillance- this will breach the Human Rights Act. Do make a note of your suspicions. Sign the note, date it and keep it safe. Do try to secure or copy documents you believe to be suspicious. Do contact your LCFS, Dawn Pendenque, on (Further reporting methods can be found on the Trust s Counter Fraud intranet page). What if I am wrong? Never be afraid to raise your suspicions directly with your Local Counter Fraud Specialist even though you may be wrong You could be right! There will be no ramifications for raising an issue you believe to be fraud, regardless of how the investigation is concluded, as long as your referral was raised in good faith. If you are uncertain of whether a referral is needed, you should contact your Local Counter Fraud Specialist anyway, for advice. The person investigated will not be disadvantaged if the investigation does not uncover any fraudulent activity. What if I am right? The LCFS will have validated the suspicions and uncovered evidence. The person under investigation will have explained their actions at a formal interview under caution. (Whatever is said can be used in a criminal prosecution). A decision will be reached regarding appropriate sanctions to be pursued. Any loss will be calculated and a decision will be made regarding appropriate recovery action. 5

6 What is a Local Counter Fraud Specialist? This person is specially trained to: Promote fraud awareness within the Trust; Prevent and detect fraud; Conduct professional fraud investigations; Answer concerns and queries; and Liaise with the Director of Finance and NHS Protect. The Role of the LCFS The creation of an Anti-Fraud culture; Maximum Deterrence of Fraud; Successful Prevention of Fraud which cannot be deterred; Prompt Detection of Fraud which cannot be prevented; Professional Investigation of detected Fraud; Ensuring effective Sanctions are applied against those who commit Fraud; Ensuring effective Redress is sought where financial losses are identified. Can anyone investigate Fraud? NO The Secretary of State Directions on NHS fraud clearly state that only a nominated and accredited Local Counter Fraud Specialist can undertake fraud investigations for each Health Body. This is to ensure that legislation governing criminal investigations (including the Human Rights Act and Data Protection Act) is not breached and as a consequence, that any potential criminal prosecution is not compromised. However The LCFS works very closely with Human Resources and professional bodies whenever a member of staff is under investigation. 6

7 What sanctions might be applied to people who commit Fraud? There are three courses of action that would be considered where fraud has been identified: Criminal prosecution or a Police caution (resulting in a criminal record); Civil proceedings (including County Court orders) to recover financial losses; Disciplinary proceedings (including action taken by a professional body). Any one, or a combination of these could be used. How do I contact my Local Counter Fraud Specialist? Your LCFS is Dawn Pendenque dawn.pendenque@nottshc.nhs.uk EMIAS, c/o Duncan Macmillan House, Porchester Rd, Mapperley, NG3 6AA You may also call the National NHS Fraud and Corruption Reporting Line (open 8am 6pm, freephone ), or report online at 7

8 Other Local Fraud Cases A former NHS Bereavement Advisor from Leicestershire was jailed for 5 years for obtaining 753,000 from deceased patients estates by making fraudulent applications to Leicester Registry Office, forging letters of authority from supposed distant relatives and suggesting to grieving families that she could relieve them of the burden of obtaining Grant of Probate. In mitigation, the defendant said that she thought of herself as a modern day Robin Hood, arguing that the money she took would have gone to the State, whilst she had better uses for it. She claimed that she had given money to the needy, including prostitutes, refugees and asylum seekers. She also admitted, however, maintaining a lifestyle she could not otherwise have afforded, including the purchase of flats, a narrowboat and high performance cars paid for in cash. A former Derbyshire hospital Doctor was struck -off by the General Medical Council (GMC) after falsely claiming 2,450 for relocation and removal expenses from her former NHS employer. The Doctor submitted an expenses claim relating to her move from London. Staff at the hospital were suspicious of the claim, which was referred to the Local Counter Fraud Specialist (LCFS) and payment refused. The LCFS investigation identified the claim to be false, as the removals company the Doctor claimed to have paid did not actually exist. The Doctor was dismissed from the hospital and she and her husband were subsequently issued with Police cautions after they admitted falsifying the claim and supporting evidence. The GMC panel described the Doctor s actions as, a pre-planned act of deception for her own financial gain and found that the receipt of a Police caution was, a serious breach of the standards expected of a Doctor. The panel therefore, concluded that her fitness to practice was impaired and she was struck-off the professional register. An arrest warrant has been issued for an NHS employee who left the country after an alleged sick pay fraud totalling almost 8,000. An LCFS investigation identified that the subject had reported sick to her substantive Derbyshire NHS employer in order to work bank shifts for another NHS Trust. The resulting false claims for sick pay totalled 7,791. At a formal interview with the LCFS, the subject admitted carrying out the fraud and subsequently resigned from her post. Following the interview a file was submitted to prosecuting Solicitors, but the subject failed to attend a scheduled Court hearing and a warrant was issued for her arrest. Information was later received indicating that the subject had left the country shortly after the Court hearing date. The arrest warrant remains outstanding and the matter has been reported to the High Commission for the subject s new country of residence. Should the subject return to the UK, she will be arrested and brought before the Court to answer the charges against her. In the meantime, attempts are continuing with a view to recovering the 7,791 in defrauded NHS funds. 8

9 Please answer the following eight questions, by placing an x in the box beside your chosen answer: 1. Who set up the NHS Counter Fraud Service? A) The Trust s Audit Committee because they are worried about the level of fraud at this Trust B) The Secretary of State so that mechanisms can be established to reduce NHS fraud nationally 2. Who is responsible for ensuring the Secretary of State s Directions are followed at this Trust? A) The Local Counter Fraud Specialist B) The Director of Finance and Chief Executive C) The Secretary of State through NHS Protect 3. How much money, diverted from the NHS through fraud, has already been recovered and put back into patient care? A) 3 million has been recovered to date B) 15 million has been recovered to date C) 65 million has been recovered to date 4. Do you, as a Trust employee, have a part to play in countering NHS fraud? A) Yes I do B) No, I have no involvement in this 5. Which of the following scenarios could be considered fraudulent? A) Staff adding shifts or hours to a timesheet that they know have not been worked B) Staff retaining a payment with their salary that they know they are not entitled to C) Staff working elsewhere whilst claiming NHS sick pay D) All of the above 9

10 6. Who can investigate a potential fraud within this Trust? A) Line Manager/ Directorate Manager B) Director of Finance or Finance staff C) Director of Human Resources or Human Resources staff D) Local Counter Fraud Specialist 7. You have evidence of fraud. What do you do? A) You go out of your way to watch the person to catch them in the act. You then confront them with the evidence B) You make an immediate note of everything you ve seen and then contact the Local Counter Fraud Specialist 8. You suspect a fraud is being carried out, but you have no evidence. What do you do? A) Don t tell anyone because you could be wrong B) Contact your Local Counter Fraud Specialist and ask for advice C) Make it known to the person you are concerned about, that you know what they are doing Please complete the following personal details: Name: Job Title: Work Address (if you do not have a work address please give the full postal address of your work base): Please return your completed answer sheet to: Dawn Pendenque Local Counter Fraud Specialist EMIAS Stapleford Care Centre Church Street Stapleford Nottingham NG9 8DB If you have correctly answered the knowledge check questions you will receive a certificate confirming successful completion of Fraud Awareness training for your personal development portfolio. 10