The Department of Health and Social Care has launched a counter-fraud strategy which identifies primary care as a key risk area to focus on in the next three years.
The new strategy will focus on exposing fraudulent claims in general practice as well as dentistry and pharmacy, the DHSC said.
It is estimated that the NHS in England is vulnerable to £1.198bn of fraud, bribery and corruption each year and preventing and detecting fraud, as well as recovery of funds, will help meet a savings target of £500m for the NHS between now and 2026, according to the Government.
Between 2021 and 2022 the financial amount vulnerable to general practice fraud was estimated at £101m, according to the latest NHS Counter Fraud Authority (NHSCFA) Strategic Intelligence Assessment report, used to develop the strategy.
In the same period, the estimated financial vulnerability to fraud for community pharmacists was £122m and for dental contractors was £61m.
During 2021/22, there were 160 allegations of general practice-related fraud made to the NHSCFA.
A DHSC spokesperson said a key part of the 2023-2026 counter-fraud strategy is ‘ensuring that, wherever possible, fraud is prevented from occurring in the first place by working with stakeholders, such as GPs, to identify any weaknesses in the system that can be closed’.
A policy paper says DHSC will take a data-driven approach and make counter-fraud a ‘part of day-to-day activity’.
One objective will be to ensure staff ‘understand fraud and how it could impact their work, and their roles and responsibilities to prevent it’ as well as make sure they feel confident to report suspected fraud early.
It also says it will ‘continue to use a range of options to deal with those who commit fraud, allowing proportionate and cost-effective action to be taken’.
Health minister Lord Markham said: ‘Every pound lost to fraudsters is a pound lost from patient care.’
He added: ‘The methods and means of attack from fraudsters are constantly changing and I am determined that we not only keep pace but anticipate their actions.
‘No level of fraud is acceptable, and DHSC and its partners will do even more in response to this threat, with an ambitious new three-year strategy target of £500m.’
Primary care is one of three targets in the DHSC’s anti-fraud strategy, also including procurement and commissioning and prevention policies.
Two GPs were suspended for 12 months in May after an MPTS tribunal found that their falsification of QOF records amounted to serious misconduct. However the tribunal accepted that their motivation was not financial gain but a bid to save their practice from being closed down by the CQC.
What does fraud in general practice look like?
The NHSCFA Strategic Intelligence Assessment 2022 report said: ‘Fraud in this area is generally considered to be the manipulation of NHS income streams by practitioners or staff members. It could also be considered activities that violate NHS contractual terms for practitioners and services provided.’
It highlights the threat of organised crime groups (OCGs) potentially colluding with GPs to obtain prescription medication for selling.
The report says: ‘Intelligence suggests non-existent or deceased patient details have been used by GPs when prescribing medication for onward trade. OCGs may fraudulently obtain prescriptions, or even collude directly with GPs themselves.’
It also said ‘it’s likely a small minority of GPs could manipulate contracts to increase profit’ by using false records or declarations to secure funding or ‘deliberately fail to remove former patients from their lists, resulting in increased Global Sum payments’.
Finally, it added there is a ‘realistic possibility that practice employees may knowingly or unknowingly be complicit in supporting contract manipulations. The staff member may not directly benefit, but could potentially register ghost patients, or intentionally fail to remove patients from surgery lists.’
A version of this article was first published by Pulse’s sister title Management in Practice