Countering Fraud Bribery Corruption Nottingham City Protected Learning

The aims of this session are: ØTo inform you about the risk of fraud, bribery and corruption that might affect the CCG and its practices. ØTo introduce the Counter Fraud Specialist. ØTo explain what you should do if you uncover possible fraud, bribery or corruption.

Why do you need to know Fraud, Bribery & Corruption? about All areas of NHS spending may be affected by fraud, bribery and corruption. It is imperative that all staff are aware of the risks that exist because staff are ideally placed to contribute to the prevention and detection of fraud, bribery & corruption. In recent years GP practices have also lost significant sums of money through criminal acts and so an understanding of these risks is also important for practice staff. We are ALL responsible for ensuring that fraud, bribery and corruption cannot easily be carried out by correctly following relevant policies and procedures and by promptly reporting any concerns that we have.

What is Fraud? The most common offences under the Fraud Act 2006 are: ØFraud by false representation ØFraud by failing to disclose ØFraud by abuse of position (Some fraud offences, committed before 15 January 2007, continue to be prosecuted under the Theft Acts)

Fraud by False Representation There are numerous ways in which somebody might falsely represent or falsify information in order to make a gain for themselves or expose another to a loss. Examples of this would include, but are not limited to: Ø The falsification of staff timesheets or expense claims; Ø Pharmacies falsely endorsing prescription forms after dispensing and/or conspiring with wholesalers and overstating the cost of specials; Ø Providers inflating the costs attributed to Continuing Care by invoicing for additional costs for services that have not been delivered; Ø Patients creating false identities in order to register with multiple practices and increase the amount of medication they are prescribed; Ø Criminal gangs purporting to represent existing creditors by using mocked up letters and other documents in order to change creditor bank details to their own.

Fraud by Failing to Disclose A fraud is also committed when somebody has a legal duty to disclose information but dishonestly fails to do so in order to make a gain for themselves or expose another to a loss. Examples of this would include, but are not limited to: Ø Staff failing to report salary overpayments and keeping the money for their own benefit; Ø Staff failing to declare that they are subject to a criminal investigation and/or prosecution where this is a requirement of their employment; Ø Failure to declare all outside interests as they arise allowing conflicts of interest to occur.

Fraud by Abuse of Position Here, a fraud is committed where somebody uses their position to dishonestly make a gain for themselves or expose another to a loss. Examples of this would include, but are not limited to: Ø A GP Practice Manager using their position of trust in order to increase their salary, redirect payments to their own accounts and/or order goods for personal use; Ø A CCG member or staff member with outside interests inappropriately using their position to influence CCG decisions in such a way as to ensure they make a gain and/or another party makes a loss; Ø A staff member using their position to cause payments to be made that would not otherwise be made (for example to the bank account in their name or that of a family member).

The Bribery Act 2010 Bribery is offering an incentive to someone to do something which they wouldn’t normally do. In the context of the Bribery Act 2010, the offence of bribery refers to both the acceptance and the offer (whether or not the offer is accepted) of a bribe. Any individual associated with an organisation acting in such a way may be prosecuted under the Act for a primary bribery offence, or for conspiracy to commit the offence with others. The Bribery Act 2010 introduced a new corporate offence meaning that organisations will be exposed to criminal liability, punishable by an unlimited fine, for failing to prevent bribery.

Taking action Processes and procedures are in place to stop fraud, bribery and corruption affecting the NHS. Despite this, it is not possible to stop all financial crime and so investigations are still required. Nationally, during the 2011/12 financial year alone: Ø£ 3. 44 m lost to fraud was recovered; ØFurther losses of £ 5. 67 m were uncovered and/or prevented. Additionally, the following action was taken against individuals: Ø 191 criminal sanctions were applied; ØCivil sanctions were handed down 123 times; Ø 461 occasions in which internal disciplinary action was taken; ØProfessional bodies applied 23 sanctions.

What have you learnt?

Why do practice staff need to be aware of Fraud, Bribery & Corruption? Choose your answer Because they are ideally placed to contribute to the prevention and detection of fraud, bribery & corruption. Because they can help to prevent fraud, bribery and corruption by correctly following relevant policies and procedures. For both of the reasons listed.

Yes, that’s right, but Staff need to be aware of fraud, bribery and corruption both because they can help to prevent fraud, bribery and corruption by correctly following policies and procedures and also because they are ideally placed to contribute to the prevention and detection of fraud, bribery and corruption. The correct answer is therefore ‘for both of the reasons listed’.

Why do practice staff need to be aware of Fraud, Bribery & Corruption? Yes, that’s right! Practice staff need to be fraud, bribery and corruption aware because they are ideally placed to contribute to the prevention and detection of fraud, bribery and corruption and also because they can help to prevent fraud, bribery and corruption by correctly following relevant policies and procedures.

Which of the following scenarios could be considered fraudulent? Choose your answer An applicant for a practice post providing false educational certificates A pharmacist endorsing a prescription with a drug that was not dispensed A Practice Manager using practice funds to purchase personal items All of the above

Which of the following scenarios could be considered fraudulent? Yes, that’s right, but … The answer you chose is a potential fraud, but so are the other two. The correct answer is, therefore, all of the above.

Which of the following scenarios could be considered fraudulent? Yes, that’s right! All the options listed are potential frauds.

The Bribery Act 2010 creates offences which can lead to action being taken against whom? Choose your answer An individual found to have either offered or accepted a bribe An organisation which has not taken adequate steps to prevent bribery Both of the above

The Bribery Act 2010 creates offences which can lead to action being taken against whom? Yes, that’s right, but … Individuals can be prosecuted if they either attempt to bribe, or accept a bribe. Organisations can also have action taken against them, including the imposition of unlimited fines, if they fail to take adequate steps to prevent bribery occurring. The correct answer is, therefore, both of the above.

The Bribery Act 2010 creates offences which can lead to action being taken against whom? Yes, that’s right! Individuals can be prosecuted if they either attempt to bribe, or accept a bribe. Organisations can also have action taken against them, including the imposition of unlimited fines, if they fail to take adequate steps to prevent bribery occurring.

Can anyone investigate fraud, bribery & corruption? (such as a line manager or a Human Resources Officer) NO It is a requirement in the NHS that only an accredited Counter Fraud Specialist can undertake fraud, bribery & corruption investigations. This is to ensure that legislation governing criminal investigations (including the Human Rights Act and Data Protection Act) is not breached and as a consequence, that any potential criminal prosecution is not compromised. However… Parallel criminal and civil investigations may take place.

What should I do if I think fraud, Bribery or corruption is occurring? Do make a note of your suspicions. Sign the note, date it and keep it safe Do try to secure or copy documents you believe to be suspicious Do immediately contact the CCG’s Counter Fraud Specialist, Ian Morris on 0116 225 6120. Don’t investigate the matter yourself or report it to anyone other than the Counter Fraud Specialist in the first instance – this may compromise any potential prosecution. Don’t undertake any covert surveillance – this may breach the Human Rights Act.

Can suspicions be reported anonymously? Yes, and anonymous referrals will be investigated. You might wish to consider that it can sometimes be useful to provide contact details in case further information is required later. Even if only a contact reference and telephone number is given, this may help with the investigation as initial enquiries might prove inconclusive and we may therefore need to make contact with the referrer to see if they have any further information which might help us progress the investigation fully. If we are given minimal contact details these will not be used to identify the person making the report.

What if suspicions are wrong? Ø Staff should never be afraid to raise suspicions directly with the Counter Fraud Specialist even though they may be wrong…They could be right! Ø There will be no ramifications for raising an issue they believe to be fraud, bribery or corruption, regardless of how the investigation is concluded, as long as the referral was raised in good faith. Ø If uncertain of whether a referral is needed, the Counter Fraud Specialist should be contacted anyway for advice. Ø The person investigated will not be disadvantaged if the investigation undertaken does not uncover any fraudulent, bribery or corruption activity.

What if suspicions are right? Ø The Counter Fraud Specialist will have validated the suspicions and uncovered evidence. Ø The person under investigation will have explained their actions at a formal interview under caution. (Whatever is said can be used in a criminal prosecution). Ø A decision will be reached regarding appropriate sanctions to be pursued. Ø Any ongoing loss will be stopped, losses incurred calculated and a decision will be made regarding appropriate recovery action.

How do I contact the CCG’s Counter Fraud Specialist? The Counter Fraud Specialist is: Ian Morris ian. morris@360 assurance. nhs. uk 0116 225 6120 360 Assurance, Stapleford Care Centre Church Street, Stapleford, Nottingham NG 9 8 DB You can also call the National NHS Fraud and Corruption Reporting Line (open 8 am – 6 pm) on 0800 028 40 60, or report online at www. reportnhsfraud. nhs. uk.

What action might be taken? There are four routes by which action can be taken when fraud, bribery or corruption is proven: 1. Civil Recovery Action will be taken to recover defrauded sums. Although this might initially be sought by agreement, the civil courts can be used if required. 2. Disciplinary Action Evidence of fraud would lead to disciplinary action and, potentially, the termination of employment for gross misconduct. 3. Professional Disciplinary Action may be taken by professional bodies such as the NMC, HPC and GMC. This could lead to the end of a fraudster’s career. 4. Criminal Sanction This could take the form of a caution for minor offences, or lead to prosecution in more serious cases. Fraud, bribery and corruption can attract significant sentences from the courts.

Scenarios

What have you learnt?

You think a false claim for payment may have been made. What should you do? Choose your answer Immediately challenge the individual or organisation presenting the claim. Contact the Counter Fraud Specialist and ask for advice. Take no action as somebody else will take action if it is incorrect.

You think a false claim for payment may have been made. What should you do? No, that’s the wrong answer, please try again By immediately challenging the person or organisation presenting the claim, or by ignoring the problem without first discussing your concerns with the Counter Fraud Specialist, you may compromise any potential criminal and/or disciplinary investigation. There is also a risk that previous false claims submitted by the same individual or organisation will not be detected and you may be accused of collusion. If you think you have identified a false claim for payment, whether or not you think that it has been deliberately falsified, you should immediately discuss your concerns with the Counter Fraud Specialist.

You think you have been presented with a false claim for payment. What should you do? Yes, that’s right! If you think you have identified a false claim for payment, whether or not you think that it has been deliberately falsified, you should discuss your concerns with the Counter Fraud Specialist, Ian Morris on 0116 225 6120.

At what point should you seek advice from the Counter Fraud Specialist? Choose your answer As soon as it is suspected that fraud, bribery or corruption may have taken place. Once a few discreet enquiries have been made to flesh out the suspicions. After gathering evidence and speaking to any individuals involved.

At what point should you seek advice from the Counter Fraud Specialist? No, that’s the wrong answer, please try again Do not launch an investigation, even if it is no more than a few simple enquiries, without first discussing concerns with the Counter Fraud Specialist. Whilst it might appear obvious what information is needed, it is often the case that this information needs to be gathered in a specific way, or with additional supporting evidence, to be useful in a criminal enquiry. By discussing your concerns with the Counter Fraud Specialist first, you can ensure that the matter is progressed in a manner suitable for both criminal and disciplinary enquiries. The right answer is therefore to contact the Counter Fraud Specialist as soon as it is suspected that fraud, bribery or corruption may have taken place.

At what point should advice be sought from the Counter Fraud Specialist? Yes, that’s right! If it is suspected that fraud, bribery or corruption has taken place concerns should be discussed with the Counter Fraud Specialist, Ian Morris on 0116 225 6120.

Can suspicions be reported anonymously? Choose your answer Yes, but concerns might not be taken seriously. Yes, the matter will be investigated fully if initial enquiries by the LCFS support the concerns. No, the referrer’s details must be given and this information which will be shared with other parties.

Can suspicions be reported anonymously? No, that’s the wrong answer, please try again Even if suspicions are reported anonymously, concerns will be taken seriously and the referrer’s details will not be shared with other parties. The correct answer is therefore that the matter will be investigated fully if initial enquiries made by the LCFS support the concerns.

Can suspicions be reported anonymously? Yes, that’s right! Even if suspicions are reported anonymously the matter will be fully investigated if initial enquiries by the LCFS support the concerns. If it is possible to provide contact details, however, it can help to support an investigation by allowing further questions to be asked where required.

What actions might be taken if evidence of fraud, bribery or corruption emerges? Choose your answer Civil Recovery of defrauded sums. Disciplinary internally and/or via professional body. Criminal sanction. All of the above.

What actions might be taken if evidence of fraud, bribery or corruption emerges? Yes, that’s correct, but If evidence of fraud, bribery or corruption emerges, the following action might be taken: • Civil recovery of defrauded sums; • Disciplinary action (both internally and via professional bodies); • Criminal sanction. The correct answer is therefore all of the above.

What actions might be taken if evidence of fraud, bribery or corruption emerges? Yes, that’s right! If evidence of fraud, bribery or corruption emerges, the following action might be taken: • Civil recovery of defrauded sums; • Disciplinary action (both internally and via professional bodies); • Criminal sanction

Case Study 1 GP Practice – Practice Manager Fraud ØA GP Practice manager was employed at one practice for 10 years. One of her duties was to oversee payroll. She abused this position to increase her own pay substantially. ØAt their peak, her earnings hit £ 17, 000 gross per month. ØShe claimed 220 hours per month in overtime alone, when she was contracted to work 156 hours per month with no overtime. She even claimed overtime whilst on a two week holiday. ØOver a two and a half year period she paid herself an extra £ 108, 615. 17 in salary plus £ 159, 244. 40 in overtime that she was not entitled to. ØShe was sentenced to 3 years imprisonment for the £ 267 k fraud.

Case Study 2 Out of Area Treatment—Hyperbaric Pressure Chamber ØUsed by divers who surface too quickly—’the bends’ ØSpecialist facilities dotted around the country, usually at diving schools etc ØThree men used the personal details of divers who had never used the pressure chamber or suffered the bends Ø 37 false patients were created to charge 12 health bodies for services not provided. £ 6, 500 each time with false charges occurring over 4 year period ØTotal of over £ 250, 000 defrauded ØTwo of the men received sentences of 5 yrs 3 months and 2 yrs 3 months with an accomplice receiving a 2 yr suspended sentence

Case Study 3 Charity Fraud—Fraud by Charity Treasurer ØCharity funded by 2 PCTs to provide advice on safe sex ØTreasurer obtained a debit card and began misusing charity funds ØBegan to live an extravagant lifestyle and purchased a Mercedes ØHe was found to have obtained over £ 140, 000 of the charities money ØFollowing his arrest, the charity went into liquidation with 5 job losses ØSentenced to 2 years imprisonment

Case Study 4 Continuing Care—NHS Manager fraud ØNHS Continuing Care Manager invented a care home ØSent 31 invoices for the care of patients whose details were taken from a register of real NHS patients receiving continuing care (including palliative care) ØInvoices were checked and verified for payment by the Continuing Care Manager ØPayments were made into an accomplice’s bank account ØFraud totalled £ 117, 812. 30. ØBoth prosecuted. £ 46, 000 was recovered from bank accounts.

Case Study 5 Pharmacy—Repeat Prescriptions ØA patient asked for a repeat prescription from their GP only to find that they had already been ordered by their pharmacy ØThe prescriptions had been endorsed as dispensed when no drugs had been given to the patient ØAfter investigating repeat prescriptions it was found that there were multiple patients in the same situation ØPolice search found £ 60 k+ in sterling, £ 2 k US dollars and a considerable sum of Indian Rupees. ØThe Pharmacist was sentenced to 12 months plus £ 45 k confiscation order

Any Questions?