NHS Counter Fraud

The Fraud Act 2006 is the primary piece of anti -fraud legislation in the UK, and it has been in force since January 2007. In contrast to the previous legislation that it replaced, the Fraud Act established a clear legal definition and offence of fraud for the first time in the UK, and for the main offences established by the Act it removed the element of deception as a characteristic of this kind of criminality. Section 1 of The Fraud Act sets out provisions for a general offence of fraud. There are several new offences created the main three being sections 2 (Fraud by False Representation) , 3 (Fraud by Failing to Disclose Information) and 4 (Fraud by Abuse of Position). The act also creates new offences of obtaining services dishonestly and of possessing, making and supplying articles for use in fraud, as well as containing a new offence of fraudulent trading applicable to non-corporate traders. 

Section 2 False Representation

Example – submitting a false timesheet, exaggerating travel expenses, working elsewhere when on sick leave from the Trust

Section 3 Failing to disclose information

Example – not declaring previous criminal convictions on an application form

Section 4 Abuse of position of trust

Example – manipulating statistics to achieve a target, creating a post for a family member

Section 6 Possession of articles intended for use in fraud

Example – having a false passport

The Bribery Act 2010 came into force on 1 July 2011, has become the primary piece of anti -corruption legislation in the UK, and is arguably one of the most far - reaching Acts of its kind in the world.

In the context of the Bribery Act 2010, the offence of bribery refers to accepting, as well as offering a bribe. The three offences most relevant to the NHS are:

Section 1 – Offering, promising or giving a bribe to another person to perform a relevant ‘function or activity’ improperly, or to reward a person for the improper performance of such a function or activity.

Section 2 – Requesting, agreeing to receive or accepting a bribe to perform a function or activity improperly.

Section 7 – Failure of a commercial organisation to prevent bribery (the corporate offence).

Corporate bodies are liable to prosecution and may suffer reputational damage if a person/organisation associated with them bribes another person/organisation intending to obtain or retain business for them or an advantage in the conduct of business.

Every NHS organisation must have a Local Counter Fraud Specialist (LCFS) in place who is responsible for tackling all fraud and bribery related allegations such as referrals and risks. This is to protect valuable NHS resources, ensuring they are being used for the appropriate reasons like providing effective patient care.

Paul Bell, Head of Anti-Crime Services Paul.Bell@miaa.nhs.uk

The Counter Fraud Champion is responsible for supporting the counter fraud agenda at a strategic level within the ICB. Including challenging the organisation’s commitment to counter fraud work and the existing level of counter fraud provision. The Counter Fraud Champion does not take part in investigations but supports the counter fraud effort at board level. For more information contact: fraudaware@staffsstoke.icb.nhs.uk

The NHS Counter Fraud Authority (NHSCFA) has overall responsibility for preventing, detecting and investigating fraud and bribery within the NHS. With the aim of protecting NHS staff and resources from activities that could have a determent effect on their ability to meet the needs of the patients and professionals. This helps to ensure a proper use of valuable NHS resources and a safer secure environment in which a good service can be delivered.

You may also report any concerns directly to NHS Counter Fraud Authority via the NHS Counter Fraud Authority National Fraud and Corruption Reporting Line (powered by Crimestoppers).

Freephone 0800 028 4060  This is manned Monday to Friday 8am to 6pm and calls can be made anonymously

Alternatively, you can report your concerns online via the following link http://www.reportnhsfraud.nhs.uk/.

If you are suspicious or have concerns:

DO tell your Local Counter Fraud Specialist immediately by email or phone – your confidentiality will be respected. We never divulge the name of an informant

DO contact the NHS Counter Fraud Authority on 0800 028 40 60 or via the online reporting form

DO keep a copy of any documentation that arouse your suspicions

DO NOT confront the individual with your suspicions

DO NOT convey your suspicions to anyone other than those with the proper authority to investigate

Investigating fraud

When we think of reporting fraud, quite often individuals think to report their suspicions to the police or to their line manager. The issues with this are that the police have to prioritise their resource and NHS fraud may not necessarily be high on their agenda, and a line manager could potentially be implicated in the fraud.

The person you should report your concerns to is the Local Counter Fraud Specialist (LCFS) who is appropriately trained to manage and investigate concerns of fraud, or to the Chief Finance Officer.

It is important that any potential fraud allegation is investigated by the LCFS as there is clear guidance as to how a criminal investigation must be conducted and any breach of this can lead to it not being deemed appropriate for prosecution.

The ICB takes part in a National Fraud Initiative exercise. This takes place every two years and includes all NHS and Councils in England.

The National Fraud Initiative (NFI) is an exercise that matches electronic data within and between public and private sector bodies to prevent and detect fraud. These bodies include police authorities, local probation boards, fire and rescue authorities, the NHS as well as local councils and a number of private sector bodies. Data for the NFI is currently provided by some 1,300 participating organisations coverings millions of transactions.

If you have any queries about the NFI, the key contact for the Trust is Samantha Bostock, Local Counter Fraud Specialist

The most common types of fraud in an ICB environment are risks relating to personal health budgets (PHB) and continuing healthcare (CHC), mandate frauds and prescriptions.

Fraud by the Patient And/or Representative:

• Deliberately mis-representing or exaggerating the patient’s condition and/or needs to receive additional funds.
• Using funds for anything other than what is agreed in care or support plans.
• Failure to report a change in need, particularly where there has been improvement in patient health and wellbeing.
• Failure to report admissions to hospital, where alternative care is provided and so CHC or PHB is not required. If in the unfortunate event of a patient death, the ICB should be notified.
• Failure to allow ICB staff to conduct required reviews, and to provide the ICB with evidence when required, for patient related financial audits.
• Failing to report conflicts of interests with care agencies.

Fraud by Care Providers or Personal Assistants:

• The under provision of services, where care is not provided in line with agreed hours and care contracts.
• Failure to notify the ICB when a patient has passed away.
• Falsely claiming for equipment or products that have not been used by the patient, such as continence products, or overstating claims.
• Claims made by family members or friends for providing patient care, when in reality they are not providing these services.

Inside Enabler Fraud:

• Staff manipulating records to allow care homes to receive payments for a patient who may be deceased or no longer receiving CHC.

Conflicts Of Interest:

• ICB staff have undeclared interests in care providers to whom patients are referred.
• Staff fail to declare they are in receipt of CHC payments on behalf of a patient.

The family of a patient in receipt of a PHB for domiciliary care failed to report the patient had passed away and deliberately misled the care agency responsible for the patient’s care.

The patient had been in receipt of notional PHB funding for six years, however due to the coronavirus pandemic the patient’s family requested to deliver the package of care themselves. During this time telephone and video call reviews and eligibility assessments were conducted by nurse assessors, however, it was noted the patient was never heard or seen. When the CHC team attempted to conduct physical reviews of the patient, the patient’s family refused to allow carers into the property and advised the patient had left the country for an unspecified period of time.

The CHC team contacted the patient’s GP who advised the patient had passed away five months earlier, but the family had not informed the ICB so PHB funding continued to be paid. This investigation is ongoing with support from external agencies.

The mother of a disabled woman was found guilty of fraud against the NHS and a county council at Gloucester Crown Court. A substantial ‘direct payment’, jointly funded by the NHS Gloucestershire Clinical Commissioning Group and Gloucestershire County Council, was granted annually to meet her daughter’s multiple care needs.

The service user’s mother diverted £17,000 from this direct payment fund into her own personal bank account.

Her daughter had both learning and physical disabilities and was in receipt of a personal health budget jointly funded by her CCG and county council. Some of the money was allocated to the service user’s sister, who was listed as her personal carer, however, the mother had grossly inflated monthly timesheets submitted to reflect the care provided.  

Enquiries were made by NHS investigators and a total of 90 timesheets had been submitted by the mother. It was established that the daughter could not possibly have worked the hours, as she had a full-time job, and was out of the country on holiday on some occasions.

In addition, the hours worked by the service user’s sister as a personal carer had been inflated.

She pleaded guilty to one count of false accounting and not guilty to three counts of fraud. The court ordered she was to pay back the money defrauded within 14 days.