Fraud Investigations NHS Trusts & Foundation Trusts

Transcription

1 Fraud Investigations NHS Trusts & Foundation Trusts A benchmarking review of criminal investigations

2 The overall purpose of the insight is to enable individual organisations to consider how they compare with others in respect of the numbers and types of fraud investigations undertaken. 1. Context One of the basic principles of public sector organisations is ensuring the proper use of public funds. The majority of people who work in the NHS are both honest and professional and believe that fraud, bribery and corruption committed by the minority is wholly unacceptable. NHS Trusts are required to take all necessary steps to counter fraud, bribery and corruption. They are also required to support the investigation of all allegations of fraud, bribery and corruption; and pursue the full range of available sanctions (criminal, civil and disciplinary) as well as seeking the recovery of NHS funds that have been lost due to criminal activity. This briefing sets out the findings from a benchmarking review of 31 NHS Trust and Foundation Trusts Fraud Referrals ( ) against national NHS Protect statistics for the same period. Appendix A provides an overall picture of local investigations across the MIAA Client Base. 2. National Top 10 Types of Fraud During 2015/2016, a total of 2,769 referrals were allocated to provider organisations, an average of 230 referrals per month. Whilst there is a varied nature of fraud referrals received across Trusts, nationally, NHS Protect has grouped NATIONAL TOP 10 TYPES OF FRAUD 1. Sickness 2. Timesheet / Overtime 3. Avoiding Charges (Chargeable Patients) 4. Working Elsewhere 5. Travel / Subsistence 6. Income Inflation 7. CV Issues 8. Right to Work in the UK 9. Unsolicited Requests 10. Sickness Certificate this data into their top 10 types of fraud. Of the fraud referrals received during 2015/16: 77% related to NHS staff fraud, of which 28% related to sickness issues which is still the most prevalent reported area, averaging approximately 50 reports per month; Patient fraud accounted for 15% of all reports, of which 64% related to overseas patients and avoiding charges ; the remaining areas identified by NHS Protect nationally were Third Party issues (4%), NHS suppliers (3%) and NHS systems (0.6%) the top 3 (excluding avoiding charges) accounted for 66% of referrals across the MIAA client base in the same period. Q: Are there areas within the top 10 types of fraud that are thematic within your organisation?

3 % Referrals 3. Overall MIAA Referral Profile in comparison with NHS Protect National Statistics The overall profile of fraud referrals varied in terms of numbers and types. Figure 1 (below) shows the number of referrals by across the MIAA client base by referral category in comparison with the national picture. MIAA Client Base in comparison with NHS Protect national statistics ALL NHS STAFF NHS SUPPLIERS NHS SYSTEMS PATIENTS THIRD PARTY Category of Referral NHS Protect % MIAA % Figure 1 MIAA Client Base in comparison with NHS Protect national statistics In addition: 28% of MIAA referrals related to sickness MIAA averages 21 referrals per month 12 Trusts had less than 5 referrals in a year 58 fraud proven cases across 23 Trusts 1 Trust recorded 27 referrals in one year 92K recorded overpayments for fraud proven cases Q: Does your organisation ensure that anti-fraud awareness activity is targeted at potential sources of referrals other than NHS staff?

4 4. Top 10 Frauds MIAA versus NHS Protect Figure 2 (below) shows the top 10 fraud referrals categorised by NHS Protect; and Figure 3 (below) profiles MIAA s top 10 fraud referrals. National - Top Ten Fraud Referrals 5% 4% 3% 2% 6% 8% 9% 13% 29% 21% Sickness Timesheet / Overtime Avoiding Charges Working Elsewhere Travel / Subsistence Income Inflation CV Issues Right to work in UK Unsolicited Requests Sickness Certificate Figure 2 NHS Protect Top 10 Frauds MIAA - Top Ten Fraud Referrals 5% 5% 4% 4% 3% 2% 32% Sickness Timesheet / Overtime Working Elsewhere 9% Travel / Subsistence Declaration - other 13% 23% Improper Payments CV Issues Leave Staff collusion - bribery Figure 3 MIAA Top 10 Frauds

5 No. Plan Days The comparison between NHS Protect and MIAA reflects the overall assessment, in that the most prevalent referrals received by Trusts relate to the activities of staff, and within those referrals working whilst sick (sickness) and timesheet/overtime fraud allegations remain the most prevalent. 5. Overview of the MIAA Client Base To provide a local comparison of fraud referrals, Figure 4 (below) shows the number of referrals by individual Trust across the MIAA client base. The green bar represents each Trust level of investment, expressed in days, in their Anti-Fraud programmes for 2015/16 (excluding Reactive Day Authorities) 160 MIAA No. Fraud Referrals per Trust ( ) No. Referrals No. Plan Days Trust Figure 4 MIAA Fraud Referrals across MIAA client base (Trusts) * Trust 26 and 27 MIAA contract commenced half way through 15/16 As highlighted above the level of referrals being made across the client base is varied; dependent on the organisations size, site locations, services provided, staffing levels, financial control environment and the investment in the Trust s Anti-Fraud services. On an individual Trust level there are significant variations across all of these areas, and the high referral Trusts tend to be those with higher staff levels and a proportionate investment in anti-fraud. Q: Is your investment in anti-fraud activity sufficient to address your fraud risk appetite?

6 No. of Fraud Referrals 6. MIAA Regional Comparison Fraud Referral Numbers/Types The following sections show a summary of the number of referrals and types of fraud referrals received during across each of the MIAA regions. The analysis is provided purely for comparative purposes and the opportunity to consider how organisations compare to other Trusts in the same region. MIAA Regional Breakdown Trust Cheshire Lancashire Merseyside Manchester Yorkshire Figure 5 Regional breakdown No. of Fraud Referrals by Region During , the Cheshire region (7 Trusts) received 46 referrals; the Lancashire region (5 Trusts) received 55 referrals; the Merseyside region (10 Trusts) received 58 referrals; the Manchester region (7 Trusts) received 75 referrals; and the Yorkshire region (2 Trusts) received 20 referrals. A direct comparison across each region would not be feasible due to the variation in Trust numbers across each area and the relevant size of the organisations; however the breakdown does provide an interesting set of data to allow MIAA to develop future benchmarking in relation to regional activity.

7 Fraud Referral by Type Regional Breakdown by Fraud Referral Type Working Elsewhere Travel Costs (Patients) Travel / Subsistence Timesheet / Overtime Staff Collusion - Rigging Tenders Staff Collusion Other Staff collusion bribery Staff collusion - Breach of Procurement Rules Sickness Certificate Sickness NHS Assets Mis-selling (Suppliers) Leave Insider Issues Inflated Invoices (Suppliers) Income Inflation Income Hours Other Improper Payments Identity Other Forged Document Declaration other CV Issues Charity Funds Avoiding Charges (Patients) Yorkshire Manchester Merseyside Lancashire Cheshire No. of Fraud Referral

8 Figure 6, above, provides an overall breakdown of the types of fraud referrals received across the regions. The top 3 consistent fraud referral types across all areas relate to sickness, working elsewhere and timesheet/overtime frauds. 7. MIAA Investigation Outcomes Across the MIAA client base, during , 23% of fraud referrals received resulted in fraud being proven; 56% of referrals resulted in fraud not proven; and the remaining 22% of the referrals were ongoing investigations at year end and were carried forward into When broken down into regions, as highlighted in Figure 7 below, a high proportion of fraud referrals have resulted in fraud NOT proven due to reasons including; insufficient evidence to substantiate the allegations made; no evidence to suggest fraudulent activity; malicious allegation; and no fraud identified. These explanations are provided to the Trust s Director of Finance at the conclusion of any investigation on a case by case basis. Yorkshire Manchester Merseyside Lancashire Cheshire N/A Fraud NOT Proven Fraud Proven * N/A relates to ongoing investigations as of 31 st March 2016 Figure 7 Regional Breakdown of Fraud Proven/Unproven Cases The following summarises the outcomes achieved following the investigations across each region. Appendix B outlines the individual assessment against each region and illustrates the thematic types of referrals received.

9 Cheshire 8 SUCCESSFUL disciplinary cases across 4 Trusts 1 SUCCESSFUL prosecution case Overpayments of 4, identified across 6 Trusts 4 Cases pending disciplinary / prosecution 13 ongoing investigations Recovery of 1, of fraud overpayments Lancashire 5 SUCCESSFUL disciplinary cases across 3 Trusts Highest value fraud overpayment across MIAA (Trust 11) Overpayments of 40, identified across 4 Trusts 6 Cases pending disciplinary / prosecution 7 ongoing investigations Recovery underway of 31, relating to fraud overpayments Liverpool 3 SUCCESSFUL disciplinary cases across 3 Trusts 6 Cases pending disciplinary / prosecution with a value of 18, Overpayments of 82, identified across 6 Trusts 1 SUCCESSFUL prosecution case 16 ongoing investigations Recovery underway of 13, relating to fraud overpayments

10 Manchester 12 SUCCESSFUL disciplinary cases across 3 Trusts Region with the highest number of reported fraud referrals in 15/16 Overpayments of 19, identified across 4 Trusts 2 Cases pending disciplinary action 16 ongoing investigations Recovery underway of 8, relating to fraud overpayments Yorkshire 2 SUCCESSFUL disciplinary cases 4 th highest number of fraud referrals received across MIAA (Trust 31) Overpayments of 14, identified 5 Cases where staff members resigned 2 ongoing investigations Recovery underway of 4, relating to fraud overpayments 8. Conclusion When considering the referral results it is important to consider that there are a number of other factors which cannot easily be quantified that may have an effect on the overall number of referrals, these can include organisational culture, location, plan days and commitment to the Anti-Fraud agenda. It is also worth considering that the number of referrals can fluctuate considerably across a year on year comparison and that a Trust with a low level of referrals can suddenly see an upturn in reports for no quantifiable reason. The key consideration for any organisation is to ensure that the workplan that is agreed for the organisation is focused on its key potential risk areas, and that the coverage undertaken is sufficient to address these risk areas and be able to provide a positive outcome when undertaking the self-assessment against the NHS Protect Standards for Providers.

11 Each year as part of the planning process the Trust s Anti-Fraud Specialist (AFS) conducts a full risk assessment which is discussed and debated with the Director of Finance with the aim of producing a plan that is reflective of the potential fraud risks facing the organisation. The results of this exercise then feeds in to the Trust Fraud Risk Assessment for the following year. National benchmarking conducted by NHS Protect identifies fraud referral activity which mirrors the experience of MIAA clients, in that the majority of referrals raised relate to Trust staff and the most common area of referral is working whilst sick and timesheet fraud. To mitigate the level of risk in these two prevalent areas, Trusts should consider if the following is robust and effective within their own organisations: Q: Has the Trust s policy relating to sickness been fraud proofed by the AFS? Q: Do Return to Work Forms include a Fraud Declaration and an appropriate question relating to any work undertaken during the sickness period? Q: Is there adequate anti-fraud awareness for Managers on preventing fraud, with particular reference to working whilst off sick and timesheet fraud as well as promoting the need for staff to declare secondary employment and conflicts of interest? Q: Does the Trust publicise recent prosecution and disciplinary cases as a deterrent to help to prevent fraud at the Trust?

12 Appendix A Local Investigations Benchmarking (MIAA Client Base) TRUST No. Staff (average WTE) No. Referrals % Fraud PROVEN % Successful sanctions % Pending Sanctions O/P Value O/P Recovery % No. Ongoing Investigations (c/f 16/17) 1 2, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

13 No. of Referrals Appendix B Regional Breakdown of Fraud Referrals Cheshire Figure 8 Cheshire Region Number of Fraud Referrals by Types of Fraud No. Referrals by Fraud Type per Trust Fraud Type Figure 9 Cheshire Region Types of Fraud per Trust

14 No. of Referrals Lancashire Figure 10 Lancashire Region Number of Fraud Referrals by Types of Fraud No. Referrals by Fraud Type per Trust Fraud Type Figure 11 Lancashire Region Types of Fraud per Trust

15 No. of Referrals Liverpool Figure 12 Merseyside Region Number of Fraud Referrals by Types of Fraud No. Referrals by Fraud Type per Trust Fraud Type Figure 13 Merseyside Region Types of Fraud per Trust

16 No. of Referrals Manchester Figure 14 Manchester Region Number of Fraud Referrals by Types of Fraud No. Referrals by Fraud Type per Trust Fraud Type Figure 15 Manchester Region Types of Fraud per Trust

17 No. of Referrals Yorkshire Figure 16 Yorkshire Region Number of Fraud Referrals by Types of Fraud No. Referrals by Fraud Type per Trust Fraud Type Figure 17 Yorkshire Region Types of Fraud per Trust

18 The Insight provides information to support organisations in comparing numbers and types of fraud investigations undertaken. It is intended to prompt and inform discussions on this important aspect of the antifraud programme. 1. Are there areas within the top 10 types of fraud that are thematic within your organisation? 2. Does your organisation ensure that anti-fraud awareness activity is targeted at potential sources of referrals other than NHS staff? 3. Is your investment in anti-fraud activity sufficient to address your fraud risk appetite? 4. Has the Trust s policy relating to sickness been fraud proofed by the AFS? 5. Do Return to Work Forms include a Fraud Declaration and an appropriate question relating to any work undertaken during the sickness period? 6. Is there adequate anti-fraud awareness for Managers on preventing fraud, with particular reference to working whilst off sick and timesheet fraud as well as promoting the need for staff to declare secondary employment and conflicts of interest? 7. Does the Trust publicise recent prosecution and disciplinary cases as a deterrent to help to prevent fraud at the Trust? We would be keen to hear your views on the issues raised and your ideas on how further benchmarking in this or other areas would be of benefit. For more information or to request a benchmarking topic please speak to your Anti-Fraud Specialist or contact: Louise Cobain, Assistant Director r&d@miaa.nhs.uk