Fraud Investigations NHS Clinical Commissioning Groups

Transcription

1 Fraud Investigations NHS Clinical Commissioning Groups A comparative 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 types of fraud investigations undertaken. 1. Context One of the basic principles of public sector organisations is the proper use of public funds. The majority of people who work in the NHS are honest and professional and they find that fraud, bribery and corruption committed by a minority is wholly unacceptable as it ultimately leads to a reduction in the resources available for patient care. CCGs 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 show a commitment to pursuing the full range of available sanctions (criminal, civil and disciplinary) as well as seeking the recovery of NHS funds that have been lost or diverted through fraud, bribery and corruption. MIAA during provided an anti-fraud service to 28 NHS Clinical Commissioning Groups across Merseyside, Lancashire, Cheshire and Manchester regions. This report sets out the findings from a benchmarking review of 11 of the 28 CCGs who received and recorded Fraud Referrals in , against national NHS Protect statistics for the same period. 2. National Top 10 Types of Fraud During 2015/2016, a total of 1,778 reports were categorised for commissioners, an average of 148 reports per month. Across NHS commissioners, nationally, these have be categorised into the top 10 types of frauds. Of all the fraud referrals received during 2015/16: NATIONAL TOP 10 TYPES OF FRAUD 1. Prescription (Patient Charge Evasion) 2. Reported Lost by Patient (Prescription Misuse) 3. Altered / Amended (Prescription Misuse) 4. Primary Care 5. False Identity (Registration) 6. Multiple registration (Prescription Misuse) 7. Dental (Patient Charge Evasion) 8. Obtained for another (Prescription Misuse) 9. Stolen (Prescription Misuse) 10.Disp. Irregularities (Dispensing / Services) Concerns in respect of NHS Patients accounted for 65% of all reports received; of which 90% related to UK patients and specifically to Prescription Misuse and Charge Evasion; which are currently NHS England responsibility. 28% related to NHS staff fraud (including primary care contractors), of which 29% related to Dispensing Irregularities and Patient Services within Pharmacies and 26% related to Sickness and Staff Collusion.

3 % Referrals 3. Overall MIAA CCG Profile in comparison with NHS Protect National Statistics for Commissioners 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 CCG Client Base in comparison with NHS Protect national statistics for Commissioners In addition: 43% of MIAA referrals related to improper payments MIAA averaged 1.75 referrals per month 17 MIAA CCGs had no reported fraud referrals 6 ongoing investigations were carried forward 16/17 1 CCG recorded 4 referrals in one year 2, recorded as an overpayment 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 for Commissioners 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. NHS Protect - Top Ten Fraud Reports 6% 7% 8% 9% 5% 5% 26% 12% Prescription Reported Lost by Patient Altered / Amended Primary Care False Identity Multiple registration 10% 12% Dental Obtained for another Stolen Disp. Irregularities Figure 2 NHS Protect Top 10 Frauds MIAA - Top Ten Fraud Reports 9% 10% 5% 5% 19% Declaration other Improper Payments 9% Income Inflation 43% Insider Issues Sickness Figure 3 MIAA Top 10 Frauds The comparison between NHS Protect and MIAA shows some significant variances in referral types this could be due to the fact that nationally the most prevalent fraud relates to NHS Patients and mostly in the areas of prescription misuse and charge evasion. Investigating such

5 CCG referrals does not fall within the remit of a local CCGs nominated Anti-Fraud Specialists, but rather NHS England. Therefore MIAA is unable to draw a clear conclusion in terms of a local profile of referrals against the national picture. Nationally across the provider sector, NHS employee sickness has been reported as the most prevalent fraud in the NHS. During 2015/16, NHS employee sickness across commissioners only equated to 3.3% of the total reported NHS employee frauds, with Staff Collusion (bribery) marginally higher at 3.7%. The national profile for NHS employee fraud differs between providers and commissioners in terms of referral types, namely due to the fact that commissioners carry additional economic crime risks with primary care contractors. The types of referrals across GP, Dental, Pharmacy, Optical, Patients and Overseas Patients includes referral types which are not comparable with NHS employees and the level of fraud risk could be considered greater, when analysing the national taxonomy of fraud issued by NHS Protect. 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 CCG across the MIAA client base. The red bar provides an outline against each CCG as to their level of investment in their Anti-Fraud programme in 2015/16 (excluding Reactive Day Authorities) MIAA No. Fraud Referrals per CCG ( ) No. Plan Days No. Referrals Anti-Fraud Plan Days Figure 4 MIAA Fraud Referrals across MIAA client base (CCGs)

6 No. of Fraud Referrals As highlighted above the level of referrals being made across the client base is consistent for CCGs; however there are still variations in terms of organisations size, staffing levels and the CCG s Anti-Fraud workplan which focuses on the raising of awareness amongst staff and highlighting appropriate methods for reporting any concerns. On an individual CCG level there are significant variations across all of these areas. 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 client base regions. The analysis is provided purely for comparative purposes and the opportunity to consider how your organisation compares to other similar CCGs in your region. MIAA Regional Breakdown CCG Region Cheshire Lancashire Merseyside Manchester Figure 5 Regional breakdown No. of Fraud Referrals by Region During , the Cheshire region (1 CCG) received 1 referral; the Lancashire region (5 CCGs) received 7 referrals; the Merseyside region (2 CCGs) received 5 referrals; and the Manchester region (3 CCGs) received 8 referrals. A direct comparison across each region would not be feasible due to the variation in CCG numbers

7 Fraud Referral by Type across each area and the relevant size of the organisations; however the breakdown does provide an interesting set of data to allow MIAA future benchmarking in relation to investigations across the client base. CCG Regional Breakdown by Fraud Referral Type Timesheet / Overtime Staff collusion - Breach of Procurement Rules Manchester Sickness Merseyside Lancashire Insider issues Other Cheshire Insider Issues Income Inflation Improper Payments Declaration other No. of Fraud Referral Figure 6 CCG Regional Breakdown by Fraud Referral Type Regionally, as well as a difference in referral numbers, 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 MIAA CCG client base relate to NHS staff fraud including sickness, improper payments and false declarations. 7. MIAA Investigation Outcomes Across the MIAA CCG client base, during , 71% of fraud referrals received resulted in fraud not proven; and the remaining 29% of the referrals were ongoing investigations at year end and have therefore been carried forward into

8 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 CCG s Chief Finance Officer at the conclusion of any investigation and vary on a case by case basis. Merseyside Manchester Lancashire Cheshire Fraud Proven N/A Fraud NOT Proven * N/A relates to ongoing investigations as of 31 st March 2016 Figure 7 Regional Breakdown of Fraud Proven/Unproven Cases Q: Does the CCG publicise recent prosecution and disciplinary cases as a deterrent to help to prevent fraud at the CCG? 8. Conclusion When considering the referral results it is important to consider that there are a number of factors which cannot easily be quantified that may have an effect on the overall number of referrals, these can include CCG co-commissioning, organisational culture and plan days. It is also worth considering that the number of referrals can fluctuate considerably across a year on year comparison and that a CCG 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

9 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 Commissioners. Each year as part of the planning process the CCG s Anti-Fraud Specialist (AFS) conducts a full risk assessment which is discussed and debated with the Chief Finance Officer and Audit Committee 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 CCG Fraud Risk Assessment for the following year. The national statistics produced by NHS Protect for fraud investigations does not mirror the identified fraud referral activity across the MIAA CCG client base, namely due to NHS England still retaining responsibility for sizable areas of primary care expenditure. What this analysis does show is there are similar levels of fraud across the MIAA CCG client base on a regional basis although these continue to be small numbers with no criminal outcomes achieved to date. To assist the CCG with understanding the fraud risks across their provider regions, the following Appendix A outlines the individual assessment against each region and illustrates the thematic types of referrals received across the MIAA Provider client base as well as summarising the outcomes achieved following the investigations across each region.

10 Appendix A Regional Breakdown of Fraud Referrals (Providers) Cheshire Figure 8 Cheshire Region Number of Fraud Referrals by Types of Fraud 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

11 Lancashire Figure 10 Lancashire Region Number of Fraud Referrals by Types of Fraud 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

12 Merseyside Figure 12 Merseyside Region Number of Fraud Referrals by Types of Fraud 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

13 Manchester Figure 14 Manchester Region Number of Fraud Referrals by Types of Fraud 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

14 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 anti-fraud programme. 1. Does your organisation ensure that anti-fraud awareness activity is targeted at potential sources of referrals other than NHS staff? 2. Does the CCG publicise recent prosecution and disciplinary cases as a deterrent to help to prevent fraud at the CCG? 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