Ishan Rajaram Countywide Mentally Disordered Offender Services Northampton UK

Transcription

1 FMU INVESTIGATOR INDABA 1-2 November 2010 Johannesburg South Africa Fraud detection and prevention The UK model Ishan Rajaram Countywide Mentally Disordered Offender Services Northampton UK

2 INTRODUCTION THE COUNTER FRAUD STRUCTURE IDENTIFYING THE RISK DEVELOPING AN ANTI-FRAUD CULTURE AND DETERRING FRAUD PREVENTING FRAUD DETECTING AND INVESTIGATING FRAUD APPLYING SANCTIONS SEEKING REDRESS

3 INTRODUCTION The Counter Fraud Service (CFS) was established in However prior to 2006 there was no precise legal definition of fraud in England and Wales. The Fraud Bill received Royal accent in April The Bill created a statutory offence of fraud. In January 2003 the NHS Counter Fraud and Security Management Service (CFSMS) replaced the NHS Counter Fraud Service (CFS). Counter fraud work ranges from issuing penalty notices as a result of patients falsely claiming prescription charges to multi-million-pound claims against drug companies for alleged price-fixing.

4 THE COUNTER FRAUD STRUCTURE Each NHS trust or Primary Care Trust (PCT) in England and Wales has a Local Counter Fraud Specialist (LCFS) assigned to it. Supported by staff in the NHS Counter Fraud Service s regional teams All staff are trained and accredited by the NHS CFS. It is a requirement that these staff have achieved the status of Accredited Counter Fraud Specialist (ACFS). This university-accredited professional qualification reflects the relevant operational needs, and provides a common standard of core skills and levels of knowledge. This course is currently provided by the NHS Counter Fraud Service's training unit (Reading and Coventry).

5 THE COUNTER FRAUD STRUCTURE The NHS Counter Fraud Service ACFS foundation-level course: Four week course Uses a realistic case scenario to explore the principles, skills, procedures, legislation and techniques required of an effective counter fraud specialist. On successful completion: Accredited Counter Fraud Specialist (ACFS). In 2008/09, these two centres trained 77 Accredited Counter Fraud Specialists (ACFS) Since 1998, 488 individuals have successfully completed training.

6 IDENTIFYING THE RISK The counter fraud process includes: creating an anti-fraud culture maximizing the deterrence of fraud preventing fraud detecting fraud quickly professionally investigate detected fraud apply effective penalties, including legal action seek to restore money or resources defrauded.

7 IDENTIFYING THE RISK The counter fraud process includes: revising policy and processes providing information to target action where it is needed identifying the nature and the scale of the problem of NHS fraud and corruption setting and monitoring the standards of counter fraud work

8 DEVELOPING AN ANTI-FRAUD CULTURE + DETERRING FRAUD Changing public perceptions and attitudes to health service fraud. The support of every member of the public in its fight against fraud. By refusing to tolerate fraud, the general public can increase the unacceptability of fraud. Inevitable part of large organisational structures? Many would defend it as a victimless crime. Even if these individuals do not set out themselves deliberately to commit fraud, their attitude does not discourage others from so doing.

9 DEVELOPING AN ANTI-FRAUD CULTURE + DETERRING FRAUD The NHS CFS s Communications and Business Development Unit: new ways to reach the largest possible number of staff, professionals and patients to emphasise the unacceptability of fraud - strengthen the anti-fraud culture. public awareness campaigns and stakeholder engagement. agreed and signed counter fraud charters, memorandums of understanding and protocols with a range of organisations. It has counter fraud agreements with regulatory and professional bodies representing over one million NHS staff and contractors (including HPC, GMC) The media team also strengthens the antifraud culture by emphasising the serious consequences of fraud. In 2008/09: 1,048 media articles that referred positively to NHS fraud work. Media analysis of this coverage: 81,820,889 opportunities to see the NHS CFS s message, with an advertising value equivalent of 917,077.

10 PREVENTING FRAUD NHS CFS s Central Intelligence Unit: identifies threats, trends and subjects based on intelligence gathered; involves linking information from a number of sources. Highlighting links between people, objects, locations and events. Deterrence and prevention significantly reduces both the number of individuals prepared to attempt fraud and the number of opportunities that exist for those who do. Decisions made about the priorities and resources needed to manage risk and provide an efficient and effective service a reduction in fraud.

11 APPLYING SANCTIONS An important part of the NHS CFS s strategy is ensuring that those who defraud the NHS receive appropriate punishment. Consideration is given to using a combination of criminal, civil, internal disciplinary and professional processes or parallel sanctions. During 2008/9, NHS CFS brought 72 prosecutions. Of these 69 have had a successful outcome (conviction). In 2009/10 the NHS CFS successfully prosecuted 65 criminal cases. Since 1998, there have been 551 successful prosecutions. During the same period NHS CFS maintained an impressive 96% successful prosecution rate.

12 SEEKING REDRESS Another of the NHS CFS s objectives is to recover money or resources lost. This can be done locally, using the administrative procedures of the NHS body or the civil law. In cases of serious fraud, the NHS CFS can apply [and has been done] to the courts to make a restraining order or confiscation order to take away a fraudster s money if it is believed they benefited from the crime. In 2008/09, the NHS CFS recovered 2,000,420. The total recovered since 1998 is more than 59 million

13 COUNTER FRAUD BUSINESS PROCESS Identify Problem Clear strategy and action plan to tackle the problem Effective structure to implement the strategy Action in all key areas Action to be taken Areas of risk Meeting targets/savings

14 TYPES OF FRAUD Professional Fraud: Practitioners [GPs, dentists, opticians and pharmacists] claiming money for treatment not actually provided to patients, treating private patients whilst they are supposed to be working for the NHS, treating private patients using NHS resources. Patient Fraud: Members of the public who deliberately do not pay for prescriptions and NHS treatments, theft of NHS property. Contractor and Supplier Fraud: A company defrauding the NHS (inflated invoicing). Staff Fraud: An NHS staff member falsifying receipts (claiming for shifts not worked)

15 CASE 1 Two dentists who owned a string of practices in the West Midlands, Merseyside and Scotland jailed for defrauding their patients and the NHS of thousands of pounds (Birmingham Crown Court, Tuesday 5 October). Some 2,500 patients came forward to assist the NHS CFS with its investigation. Twelve former members of staff, including three dentists, gave evidence for the prosecution. His Honour Judge Juckes The NHS cannot operate unless it can rely on the honesty of professionals.

16 CASE 2 A hospital worker who claimed nearly 20,000 for shifts he did not work sentenced to 12 weeks' imprisonment suspended for 12 months plus 150 hours of unpaid work and ordered to repay the misappropriated funds within two years (Stoke on Trent Crown Court, Friday 1 October). MB submitted false claims for work from 1 st January to 26 th July 2009, complete with forged authorising signatures. In fact he had only worked one shift during this period. The investigation was completed in partnership with Staffordshire Police, who arrested MB at home on 29 th January 2010.

17 CASE 3 A bereavement officer at Birmingham Children s Hospital, who defrauded her employer of nearly 26,000 sentenced to a 12 month supervision order after an investigation by the NHS Counter Fraud Service (Birmingham Crown Court, Tuesday 7 September, 2010). Hospital managers received a tipoff. The outcome at court will deter others from exploiting the NHS in similar ways.

18 Ishan Rajaram is a medical practitioner, qualified at the University of KwaZulu-Natal, Medical School. Seven years working within the Criminal Justice System in London England and for five years he was employed as an Associate Specialist in Forensic Psychiatry at the largest not-for-profit mental health care organisation in Europe. Here he was involved in the commissioning of new psychiatric inpatient hospitals. Worked at HMP Wandsworth, the largest prison in London in a clinical capacity. He consults to the NHS Forensic Services and is involved in the commissioning of new psychiatric residential homes. He is completing a Master of Business Administration (MBA) at Edinburgh Business School with completion scheduled for December For his Doctorate in Business Administration (DBA) he intends to undertake research that will assess the economic impact of fraud within the health sector in South Africa.