Preventing fraud against the NHS

The NHS Counter Fraud Service (NHS CFS) investigates any suspicions of fraud, resulting in convictions that attract public attention. Work to prevent fraud may have a lower profile but is the preferred option. It protects the public purse and prevents the diversion of valuable NHS resources from patient care.
    
The NHS CFS works closely with the Department of Health and other stakeholders to recommend, develop, implement and evaluate NHS policy and procedures. There are four key elements that should be built into all policies and systems to minimise the risks of fraud. We recommend having clear rules and evidence-based procedures, ensuring accountability, proper monitoring and appropriate sanctions.

Clear rules
Some policies and systems are straightforward, such as timesheet recording, while others are inherently complex, with caveats and exemptions that require interpretation and judgement – for example, procurement and contracting. Clear rules or guidance to underpin each policy, be it the simplest or most complex, is the first step to reduce ambiguity and minimise mistakes. This will also make it more difficult for a reasonable excuse to be provided by someone who is defrauding the NHS.
    
Wherever a claim or an exemption is made, systems should be designed to require original evidence to support the claim – for example, receipts for expense claims or a counter signature on a timesheet for agency staff. Such evidence helps validate any payment and makes monitoring more effective.
    
Systems should be simple and usable, while opportunities to defraud should be identified and reduced wherever possible. This all helps to make it clear what a person may and may not do.

Accountability
The second step should be a requirement for everyone responsible to be held to account for their actions. This could mean signing a proper declaration on an overtime claim, NHS Bursary application or a contractor’s statement of performance. A good declaration will help deter those tempted to defraud, it will assist in the event of an investigation, and it will ensure any legal issues regarding monitoring arrangements are dealt with properly.
    
An effective declaration will: confirm that details provided are correct; confirm that the signatory is aware of the consequences, including any sanctions, if they have provided false information; and permit the sharing of relevant details in the claim or application to enable effective monitoring to take place.

Of course, some systems and processes will not easily lend themselves to declarations on forms for each transaction, so consideration needs to be given to contractual terms for individuals or companies and to retaining a proper audit trail of instructions, and acknowledgements of those instructions. This all helps to define who is accountable.

Monitoring
Any system involving payment of money, claims or granting of exemptions from charges is at risk from fraud or error, so effective monitoring is necessary to identify any such potential problems.

Checks should validate the claim or payment against original documents and evidence to support the transaction. A good monitoring system will have pre-defined parameters and be supported by guidance to ensure those operating it follow a clear and consistent methodology.
    
An appropriate percentage of checks are needed, either taken from a random sample or targeted at the highest risks. The system should have a process to refer any suspicions of fraud to the Local Counter Fraud Specialist/s in the NHS body concerned, or to the NHS CFS via the NHS Fraud and Corruption Reporting Line: 0800 028 40 60.

Evidence gathered as part of a fraud investigation must comply with the Police and Criminal Evidence Act, so it is important that as soon as a suspicion is identified, the person routinely monitoring takes no further action until a trained counter fraud specialist is involved. The outcome of any anomalies found by the monitoring should inform revisions to the policy or procedure and any guidance, as discussed above. This all helps to see if a person committed fraud or not.

Sanctions
Lastly, while a great many cases of fraud can be prevented, it is unlikely that every person minded to exploit the system for their own gain will be stopped before they offend.

Where fraud is not prevented or deterred and the monitoring identifies a case of fraud, appropriate sanctions will need to be considered. These may include criminal, disciplinary or civil proceedings to recover any losses, following investigation by the specialists. When developing a policy or system, consideration may also be given to including a sanction specifically for that process – for example, a fixed financial penalty or removal from the scheme. This will help prevent fraud happening again.

Martin Wiles is Head of Policy and Research at the NHS Counter Fraud Service.