Suspicious minds at the NHS

THE NHS loses an estimated 2 billion a year to fraud around five per cent of its total budget, and roughly equal to the amount of extra money that Prime Minister Tony Blair recently said he would like to put into the cash-strapped health service.

Despite this drain on scarce resources there has never been a comprehensive strategy for dealing with NHS fraud. But all that could be about to change, thanks to the recent establishment of an NHS fraud "squad".

The NHS Directorate for Counter Fraud Services (DCFS) went fully operational last November. Its long-term mission is to "reduce the amount of fraud in the NHS to an absolute minimum within 10 years."

Targets include fraudulent patients (mainly avoidance of prescription charges), GPs, dentists, pharmacists, opticians (often falsely inflating fee payments), hospital administrators and even doctors who tamper with clinical trial results.

DCFS South East regional team manager Phil Shepard is on the front line of fraud detection. He has investigated cases involving NHS staff ranging from large commercial frauds to relatively petty embezzlements.

A former Metropolitan police CID officer, he is unsurprised at the level of NHS fraud. The further he and his colleagues dig, the more is uncovered: "I really don't have enough time in the day to deal with all the stuff I have to deal with," he says.

His varied work includes surveillance and interviewing of suspects, and preparing cases for civil proceedings to pass to the police.

Already a number of alleged frauds have started their journey through the justice system.

He says: "I have no doubt that we will have an impact. If we find there are people who are defrauding the NHS they will be dealt with."

Behind the "front" line a team of specialists is engaged in building up a detailed picture of NHS fraud: the various kinds of fraud; where it happens, who perpetrates it, how much it costs the health service; and how to prevent it. Zo' Meeson, DCFS executive officer, is involved in setting up a fraud "whistleblower" helpline which goes live in April. This will do more than simply catch fraudsters, she says; it will act as a deterrent: "It shows NHS staff we are serious about tackling fraud."

DCFS strategy officer Alex Nagle designs ways of measuring the level of fraud: "We need robust processes and reliable estimates. How much fraud is there in the NHS? The answer is we don't know yet." Knowing where the fraud is will allow the directorate to concentrate its resources more effectively to maximise the detection of fraud, says Alex, and that ultimately means more money made available for patient care.

The outcome of its first antifraud initiative has been encouraging; the introduction of a new series of administrative checks resulted in a 40 per cent cut in prescription charges, saving the NHS 40m.

The directorate admits that much has to be done to change widespread perceptions that NHS fraud is either exaggerated, or non- existent, particularly among the caring professions.

DCFS specialist research officer Meirav Elimelech says the high public reputation of NHS staff means it can be a shock when fraudulent individuals are uncovered: "You tend to assume that doctors or pharmacists are pillars of society.

You don't expect them to be defrauding the NHS."

She adds: "It's not to do with being 'bad' or 'wicked'. Fraud is opportunistic. You are not going to do it unless you have got the opportunity to do it. It's our job to remove that opportunity."

Quality inspector Zo' Porton says there's a real buzz of enthusiasm around the DCFS; people feel positive about shaping a new organisation that can make a difference.

She says: "Everyone is very committed. Like everyone else, I want to make sure money is being used for patient care and going where it should be going."

Copyright 2000
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