Why isn’t the NHS taking fraud more seriously?

It’s surely common knowledge now that the NHS is under massive cost pressures. This weekend saw the Royal College of GPs up its publicity campaign with alarming warnings that GPs will become ‘extinct’ if they don’t get a greater share of NHS funding – currently standing at 8.39% of the overall £110Bn NHS budget.

But did you know that estimates of NHS fraud across the whole system amount to over a third of the total amount that GPs receive? Some go further. Total losses of at least 3% are a reasonable assumption if the NHS is no worse or better protected than the best found international healthcare organisations, which equates to over £3 billion per year. Jim Gee who set up the original NHS Counter Fraud Service in the 1990’s now estimates fraud account for closer to the equivalent of 80% of what we spend on GPs, a whopping £7bn. Either way we are talking enormous sums, and it is the subject of tonight’s BBC Panorama programme.

The modus operandi of fraudsters are well known:

A. Claiming for work that does not exist e.g.

• Professionals creating ghost patients

• Professionals working elsewhere while off sick

• Managers making fake timesheet and payroll claims

• Suppliers making bogus invoices

B. Claiming for higher value items e.g.

• Professionals dispensing a cheaper product than claimed for

• Professionals altering patient treatment details

C. Securing materials/services on false premises e.g.

• Community Professionals claiming for excess car mileage

• Patients obtaining controlled drugs

D. Insider theft e.g.

• Professionals theft of prescription forms

• Professionals theft of inventory

E. Fraud and error e.g.

• Patients wrongful claim of exemption from fees

• Professionals over-prescribing, requested or administered

Since 2020health’s reports of 2011 highlighting the problems of fraud in the NHS (both alone and in partnership with the Centre for Counter Fraud Studies at the University of Portsmouth and the European Healthcare Fraud and Corruption Network), there appears to have been no systematic action taken to reduce fraud in the NHS. Indeed, since the 2012 Health Act, with more contracts being procured and an increase in transactions, the opportunities for fraud will have expanded. And whilst opportunities for fraud have increased, the workforce dedicated to reducing and detecting fraud in the NHS (NHS Protect) has been reduced by 21% and none of the recommendations we made three years ago have been acted on.

Quite simply what we previously called for is still required:

1. An end to secrecy – Clarification of NHS Trust responsibility around reporting of counter fraud activity and spending to the public to enable transparency and accountability. Foundation Trusts can still hide behind ‘commercial sensitivity’ clauses and refuse to reveal data on losses.
2. Outcomes not process – Change in the reporting requirements to provide clear and accurate outcomes information about how much losses are, to what extent they have been reduced, to what extent fraud losses have been recovered, and what preventative measures are in place. There is still no legal requirement for an NHS organisation to know or publish their financial losses. If they don’t know what they are, how can they start to tackle them?
3. Consequences for concealment – Fine NHS Trusts who do not publish their counter fraud outcomes.

As demand on NHS services grow, we are perplexed as to why politicians have been so complacent about fraud. After we published our previous reports, Department of Health officials simply dismissed the numbers as being over inflated. Maybe so, but until NHS Trusts and now Clinical Commissioning Groups (CCGs) as well, start measuring their losses, we will never know how much money that should be being spent on patient care is actually ending up in the pockets of those in whom we are placing so much trust. GPs through their CCGs could lead the way by measuring their losses and showing the rest of the NHS that being accountable for your budget also includes making sure it is all spent on patients.