Tackling Fraud in NHS of Scotland - Essay Example

Tackling Fraud in NHS Scotland In this report I am going to investigate how fraud in NHS can be reduced. In a broad definition fraud is a deliberate misrepresentation which causes another person to suffer damages, but looking at this with a legal perspective this is only one small element of actual fraud. Giving an example of this, a salesman may lie about his age or place of birth but deliberately misrepresenting the product will be a fraudulent act. Fraud in NHS is a type of crime which can be difficult to identify. Mostly it’s a non-violent and entirely paper-based activity, in which fraud tends towards invisibility and there may not be any immediately apparent victim. Fraud in NHS Scotland costs an astonishing £100 million a year (Kelbie, 2008). However, NHSScotland Counter Fraud Services (CFS), which was set up as a deterrent safeguard against further illegal activity, is empowered to discover, examine and trial cases of potential NHS fraud. “It is estimated that £14 million in NHS fraud savings have been made since the agency was established in July 2000.” (Crown, 2008). The Crown proudly announced that the NHS savings recouped from potentially fraudulent activity is equal to the staffing costs of nearly 750 additional nurses or 120 extra consultants. In the alternative, it would fund enough resources for upwards of 2000 hip operation replacements or nearly 100,000 MRI scans, or nearly 200,000 emergency facility attendances (Crown, 2008). In the area of greatest savings, it was determined from two investigations that the greatest annualised cost recoupments were in gold dental inlay fraud reduction and ophthalmic service containment. These two spearheaded and particularized strategic investigations returned more than £2.2m on an annualised basis. The enormity of the savings in just two areas of concern highlights just how pervasive and ubiquitous the problem is (NHS, 2005/2006). Overall the counter-fraud roundups have had notable success. During the past fiscal year 2007/08, the programs have returned £4.17m worth of savings but figures are on the rise and could reach £7.5m as ongoing investigations realise completion. Remarkably, it is reported that since 2000, “the CFS has recovered £20 million (eGov, 2008) and brought 482 successful prosecutions” (Dicken, 2008); since establishment in 2000 (eGov, 2008). Common Fraudulent Schemes The fraudulent activity most rampantly perpetuated involves patients who claim exemption from NHS charges for “dental treatment, optical vouchers and prescription charges; using false identities or fake prescriptions, and using the NHS for treatments free of charge.” (Kelbie, 2008). Other activities of illegal demerit include altering dates on pre-payment certificates, and exploiting the NHS in the promotion of Health tourism; thereby gaining the medical healing and procedures free of charge, while undoubtedly getting kick-back from the foreign customers. The NHS staff themselves are involved in the fraudulent scheming. For example, a staff person may claim non-existent travel or sustenance expenses, or just inflate mileage. Other common schemes include falsifying overtime sheets vouching hours never worked; or claiming medical service as privately performed; clocking in for others for shifts not worked, as well as abuse and inappropriate use of fuel cards for filling own or other’s vehicles (Crown, 2008). Dental and ophthalmic abuse appears to be most prevalent; with falsified claims for precious metal inlays most often quoted when in fact other cheaper metals were used. In the ophthalmic area, claims for multiple pairs of eyeglasses are common where only one is supplied; or alternatively a proffered claim for full replacement glasses when only small or non-existent repairs were effectuated. Also easily claimed falsely are additional add-ons such as tints, bifocals, or inflation of the frame price where more utilitarian models were actually purchased (Crown, 2008). Initiatives The Scottish Government has created a new strategy building on the existing. The new strategy introduces new initiatives to target the few miscreants who engage in fraudulent activity against the NHS. The primary new focus is to raise cognition of the potential activity by means of selecting a principal counter fraud person. The concept is to form a multiple-level liaison between this champion of fraud reduction, the audit committee and NHS HR managers to form a 3-headed sentinel of fraud intervention. (Smith, 2008). There is also the proposal to promote increased awareness through information, including continued staff education, as well as written and electronic awareness material, including DVD’s and other e-learning guides to raise the knowledge of managers as to appropriate action to take when confronting activity that is potentially unethical or fraudulent. (Smith, 2008). Another new strategy was promoted in early 2008 “by Nicola Sturgeon, Cabinet Secretary for Health and Wellbeing” (Smith, 2008); in which a no-tolerance plan aims to prevent fraudulent activity from within NHS itself, including “staff clinicians, contractors and patients. The emphasis of this plan is to identify behavioural manifestations which seem to be prevalent during fraudulent enterprise (Smith, 2008). Furthermore Cabinet Secretary Sturgeon implored that "Protection against fraud must begin at the earliest stages when healthcare policies, systems and procedures are being designed, before they are finally agreed and rolled out (Crown, 2008). Additionally, for maximum deterrent effect, modern counter-fraud thinking is expected to embrace 'triple tracking' methodologies, which encompasses counter-fraud deterrence on multiple disciplinary fronts, including criminal, civil and other punitive action where appropriate (Crown, 2008). Additionally, computer aided-and abetted fraud is also up nearly 33% and the NHS hopes to employ more modern computer technology to track and undermine this approach (Pike, 1998). Partnerships and Charters to fight Fraud In the ongoing fight to counter fraudulent activity, the “RCN Scotland and NHS Scotland Counter Fraud Services (CFS) have teamed up to sign the “Counter Fraud Charter, demonstrating a joint determination to tackle fraud within NHS Scotland.” (RCN, 2008). Both “RCN Scotland and CFS are both committed to zero tolerance on fraud and have been working together over the past year to develop this Charter” (RCN, 2008). Scotland RCN Director Theresa Fyffe said, in support of the Charter agreement that “It aims to support staff, not blame them.” (RCN, 2008). The intent of the Charter is to help the nursing establishment and RCN Scotland membership navigate through the often multifaceted and intricate machinery that comprises the fraudulent activity. The idea is to promote simplicity and openness, creating avenues of approach and defense to combat a ubiquitous problem. The obstacles require awareness of the activity as well as the access and understanding of the potential procedures that are useful and ameliorative (RCN, 2008). There is also the additional partnership between Counter Fraud Services (CFS) and the General Medical Council. This partnership takes the form of a “Memorandum of Understanding (MoU)” which lays out the respective responsibilities and roles each party is to assume, and where their joint duties meld together for partnered and cooperative response The values, beliefs and philosophies forming their relationship is contained within the four corners of the document (NHS, GMC 2008). The role of the GMC differs from the CFS in the respect that it assumes the power to uphold the United Kingdom medical registry. The Medical Act of 1983 imbues the GMC with the necessary statutory empowerment to approve, reprimand or remove (even to impart certain restrictions upon) a medical doctor from the registry for malfeasance or other fraudulent act; or simply for not assuming the responsibility of proper vigilance. These powers apply across all medical employment sectors within the greater United Kingdom (NHS, GMC 2008). Scare Tactics Cloud NHS Strategy The NHS fraud-unit may have tarnished its glossy reputation somewhat by vigilantism tactics. Thousands of threatening letters from the NHS crack-down squads have hit nearly 50,000 elderly pensioners who have been intimidated into not claiming their rightful benefits under the law, as they fear legal and punitive backlash that could amount to 522 pounds in fines and pursuit by the fraud units for failure to cooperate the letters warn. So in their haste and anxiousness to retrieve millions in previous losses; they may in fact be relegating the truly needy and those intended to be served with lack of adequate medical care (Scott, 2003). Whether or not this scare-mongering continues since first reported is unknown. NHS Fraud Prevention Enhanced by Media Participation Regardless the success of NHS Fraud strategy and implementation, media cooperation and involvement is critical in the overall strategy to reduce NHS fraud. Where a pharmacist or other medical practitioner is caught and the story makes the headlines, it not only brings embarrassment to the perpetrator, but it acts as a significant psychological deterrent for all future parties contemplating similar schemes (Young, 2004). Therefore the overall aims are accomplished through the creation of, and the mass dissemination of an anti-fraud and anti-corruption culture, perpetuated by highlighted sensationalistic heralding of successes in fraud prevention and deterrence. Ultimately public attention is raised and the reputation of the NHS Scotland services is enhanced as well as their economic circumstances. Overall, everybody benefits in the end, with more money and better services to care for those in greatest need (Young, 2004). Still it is important to recognize that a balance must be struck if the overzealousness of the anti-fraud units is not to infringe on the rights and medical requirements of the populace at large. Bibliography Crown. (2008, January). Tackling NHS Fraud http://www.scotland.gov.uk/News/Releases/2008/01/28100915 Dicken, P. (2008, Sept.) NHS warned to be vigilant on fraud. Public Finance. London: pg. 12, 1 pgs http://proquest.umi.com/pqdweb?did=1585897221&sid=4&Fmt=4&clientId=77774&RQT=309&VName=PQD eGov. (2008, November). Success in reducing NHS fraud in Scotland Source: Scottish Government. http://www.egovmonitor.com/node/22100/print Kelbie, P. (2008, January). Crackdown on £100m NHS fraud in Scotland. The Observer. http://www.guardian.co.uk/society/2008/jan/27/nhsfraud.scotland NHS, GMC. (2008, January) National Health Service Scotland Counter Fraud Services and the General Medical Council. http://www.gmc-uk.org/about/partners/nhs_scotland_counter_fraud_services.asp NHS, (2005). NHS National Services Scotland, NSS Counter Fraud Services – 2005/06 Annual Savings http://www.nhstayside.scot.nhs.uk/about_nhstay/commitees/03_ac/26042007/78606.pdf Pike, A. (1998, February). More managers 'committing computer crime'; [London edition 2]. http://proquest.umi.com/pqdweb?did=26523836&sid=2&Fmt=2&clientId=77774&RQT=309&VName=PQD RCN. (2008, February). NHS Scotland counter fraud charter signed Royal College of Nursing. http://www.rcn.org.uk/newsevents/news/article/scotland/nhs_scotland_counter_fraud_charter_signed Smith, A. (2008, Jan.) Strategy to Combat NHS Fraud in Scotland. St Andrew’s House, Regent Road, Edinburgh EH1 3DG www.scotland.gov.uk. http://www.sehd.scot.nhs.uk/mels/CEL2008_03.pdf Scott, M. (2003, August) NHS FRAUD SQUAD TERRORISE OUR OAPS; SCARE TACTIC: Threatening letters leave old folk living in fear. Article from: (Glasgow, Scotland). http://www.highbeam.com/doc/1G1-107152307.html Ward, S. (2007, January). Gee leaves NHS anti-fraud service on a high of £811m saved Public Finance. pg. 6, 1 pgs http://proquest.umi.com/pqdweb?did=1254526971&sid=5&Fmt=3&clientId=77774&RQT=309&VName=PQD Young, G. (2004, August). “Together, we raise awareness to stamp out fraud and corruption” http://www.mz.gov.pl/wwwfiles/ma_struktura/docs/zal_18_korupcja_051220007.pdf Read More